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John Irvine

Is the Foreclosure Crisis Making People Sick?

The housing crisis that precipitated our ongoing recession began with the foreclosure of 15% of US mortgages. There remains substantial disagreement, however, about whether and how public health departments should specifically address health problems experienced by the people who lost their homes in this crisis. While poor housing quality and homelessness have been statistically correlated to illness for many years, some argue that the correlation merely represents the influence of other factors that are common among people with housing insecurity: indebtedness and inability to pay for medical services, unemployment and associated insurance loss, food insecurity, mental illness, substance abuse, or family instability resulting in poor healthcare seeking or inadequate medical adherence.

As a result, it’s not obvious whether having health departments improve housing availability or quality will necessarily improve health conditions among the groups who face foreclosure. If better housing is really directly linked to better health outcomes, then health departments should expect a return on their investment in housing programs for this group. But if the statistical finding is merely secondary to other factors like indebtedness, then the money might be better spent elsewhere, for example in debt repayment programs, or in preventing the type of predatory banking practices that lead to the foreclosures. In this post, we try to answer the question: is the foreclosure crisis making people sick? And if so, what interventions have been shown to work, if any?

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From Couch Potato to Quantified Self

I’ve been interested in the growing population of folks who self-track objective data for health purposes.  The phenomenon is referred to either as personal informatics or the Quantified Self.  Both concepts have a following and both are intimately tied into the value of connected health.  Connected Health adds value in two fundamental ways:  self–care and just-in-time care.  In both cases, objective, quantified data is a critical piece of success.   For those individuals who are even a bit motivated to improve their health, quantified, objective information leads to insights that prompt behavior change.

I had a chance the other day to catch up with Gary Wolf, who is one of the founders of Quantifiedself.com, a frequent contributor to the New York Times Sunday Magazine and a Contributing Editor at Wired.  We had an inspiring discussion about the intersections of Quantified Self and Connected Health.

Gary was a bit out of breath, having just wrapped up the first Quantified Self Conference in Mountain View, CA.  Gary was very excited about the conference and its impact.  More than 100 projects were presented, 60 talks were given and more than 25% of participants presented.  When I asked him what was ‘the hook,’ i.e. why is QS taking off so fast, his response was that, “people are reaching the realization/hope that personal data have personal meaning.”  We both agree that the growing interesting in quantification is bringing us beyond the ‘data is geeky’ stage to an era where there is a real movement around the collection of data and the use of that data to gain insight about health and affect behavior change.Continue reading…

Yes, The Federal Exchanges Can Offer Premium Tax Credits

Whatever else the Affordable Care Act may accomplish, it has provided endless entertainment for law professors.

The latest ACA kerfuffle involves the discovery by critics of the ACA of an ACA drafting error that would seem to deprive millions of uninsured Americans of tax credits to purchase health insurance and invalidate regulations recently proposed by HHS and the Treasury Department. The mistake is found in section 1401 of the ACA, which creates a new section 36B of the IRC. Two subsections of 36B ((b)(2)(A) and (c)(2)(A)(i)) suggest that premium tax credit eligibility under the ACA depends on the applicant being enrolled in a qualified health plan “through an Exchange established by the State under section 1311.” This would in turn suggest that individuals enrolled in a qualified health plan through a federal exchange established under section 1321(c) would not be eligible for premium tax credits, contrary to the recent proposed regulations.

That this is a drafting error is obvious to anyone who understands the ACA. Section 1311 of the ACA requests the states to establish American Health Benefit Exchanges and sets out the duties of the exchanges. Section 1321 of the ACA, however, provides that if a state elects not to establish and exchange or fails to do so, HHS must “establish and operate” an exchange in such a state and “take such actions as are necessary to implement” the other requirements of title I of the ACA, which includes section 1401. There is no coherent policy reason why Congress would have refused premium tax credits to the citizens of states that ended up with a federal exchange. None of the CBO reports scoring the ACA suggest that premium tax credits would only be available though 1311 state exchanges and not through 1321 federal exchanges. It is, finally, highly unlikely that the House, whose bill included only a federal exchange, would have approved a bill that only provided tax credits through state exchanges but not through the federal exchange.Continue reading…

Another Modest Proposal* – Paying for Physician Training

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact, a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

There are, of course, longer training programs.  Internal medicine fellowships are 2 to 3 years on top of a 3-year residency.  There was a time when this made sense, since the idea was to educate competent general clinicians and then for them to specialize in a narrower field.  Given the limited general physician work of, let’s say, cardiology, one could easily argue that the 3 years of internal medicine training are wasted. Should cardiologists, therefore, be credited with 23 or 26 years of training? It would obviously be more efficient to move these physicians directly from medical school into the cath lab.

There are some physicians who keep going on and on in their training, completing one residency and then another. One fellowship and then another.  CMS must come up with a numerical way to appropriately compensate these individuals for their time, yet discount it for any lack of relevance that their training might have for performing a particular procedure.  Take, for example, the resident who completes his general surgery training then goes on to do a fellowship in vascular surgery, then goes into practice and limits his practice to the laser closure of veins, a technique he learned in a weekend CME meeting.  Should this physician’s income reflect 7 years of training or 3 days?Continue reading…

2011 Costs of Care Essay Contest

Do you have a story about a medical bill that was higher than you expected it to be? Or a time when you wanted to know how much a medical test or treatment might cost? How about a time you figured out a way to save money while still delivering high-value care?

As part of our second annual essay contest, Costs of Care, a nonprofit group based in Boston, is offering $4000 in prizes for anecdotes like these that illustrate the importance of cost-awareness in medicine. Judges will include former White House Budget Director Peter Orzsag, former United States Surgeon General C. Everett Koop, Governor Jennifer Granholm, women’s health and cancer research advocate Dr. Susan Love, and Harvard University Provost Dr. Alan Garber.

The mission of Costs of Care is to expand the national discourse on the role of care providers in controlling healthcare costs. The stories we receive as part of our second annual essay contest will provide everyday examples from across the nation that illustrate the power patients and healthcare workers have to curb costs at a grassroots level. Many of the submissions we receive will be published right here on The Health Care Blog.

Submissions should be no longer than 750 words and are due by November 15th. More details are available at www.CostsOfCare.org/essay. Email submissions to contest@costsofcare.org.

You can also read about our winning essays from last year here.

If You Get What You Pay For, How Much Should You Spend?

I have been thinking lately about the state of the field of health services research. Having plied this trade for nearly 30 years, it struck me that many of the unanswered questions that I encountered as a doctoral student remain unanswered. I plan to post occasional blogs in which I pose these questions, discuss the state of the research, and explain why it is critical that we come up with better answers. The first question is really the big kahuna: If you get what you pay for, how much should you spend?

Everyone seems to agree that the U.S. spends too much money on healthcare. This has led many to embrace machete policies: Slash payments to doctors. Slash payments to hospitals. Slash payments to drug companies. Slash the number of specialists. Slash, slash, slash.

There is abundant research that past machete policies directed towards healthcare providers have adversely affect healthcare quality and access. There is also abundant evidence supporting the view that machete policies would curtail medical innovation. Medical providers and drug companies cite this evidence whenever they are threatened with payment cuts, proclaiming that any reductions from current levels would be disastrous for the American public.

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The Need for a Level Playing Field for Physician Pay


Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much.  It’s part of the same ethic that teaches us not to criticize another doctor’s care.

But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest.  If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?

History shows that physician pay rarely follows value, but rather aligns with power.  When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own.  Power and wealth followed.

About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT and MRI scans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.

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The ‘CSI Effect’ Hits Medicine

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work help.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study.  According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S.  Some call it the “CSI Effect,” after the TV show, CSI.  In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty.  Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis.  They’re often surprised to see how it really works.  Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis.  Doctors often order high-tech tests because patients expect it.Continue reading…

Steve Jobs: Healthcare Revolutionary?

He killed the audio CD but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the world wide web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

Really? The practice of medicine?Continue reading…

Finding A Quality Doctor

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –

I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.Continue reading…

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