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John Irvine

Government Works (Really)

Conventional wisdom has it that government has lost its way. It’s out of touch and out of control. It has shut out the voices and concerns of everyday Americans. Democracy — or rather, taking the concerns of ordinary Americans into account in the democratic, lawmaking process — is a notion so farfetched as to be laughable.

But what if that weren’t true?

As a private citizen — a native Bostonian with a wife and three kids who seem to think I’m okay, a job I enjoy, and a rabid Red Sox fixation — I set off to see if I could have a say that made a difference.

And here’s the clincher: It actually worked. Really.

Here’s the setup: The state of Florida had in its law a rusty old provision that made it all but impossible for an insurance company that sold insurance abroad from having offices in Florida — even though it would not be selling insurance in the state. That law cost the state untold number of jobs and tax revenue for no apparent reason. Even Florida lawmakers from both sides of the aisle were perplexed as to how and why that initial law had come to be.

This meant American companies like mine that serve the Latin American market were barred from locating in Florida, the gateway to Latin America and home of some of the country’s highest-skilled bilingual workers.

Gov. Rick Scott, I knew from reading the papers, was keen to add jobs for Floridians. So was Insurance Commissioner Kevin McCarty. So was every lawmaker in the Florida Legislature.

So I hopped on a plane (well, lots of planes), knocked on their doors, and made my case. I explained that some simple changes to the old law would create jobs and new revenue for the state — all without spending a dime of government “stimulus.” I worked with staff and legislators on both sides of the aisle — Republican Reps. Bryan Nelson of Apopka, Carlos Lopez-Cantera of Miami, Sen. Garrett Richter of Naples and Democratic Sen. Chris Smith of Fort Lauderdale among them — to create the few brief, sensible improvements, and a few months later, the Legislature included the idea in HB 1087. It took effect this month.Continue reading…

Harnessing the Yottabytes

What if medicine in the US is just like the internet? What if it is just as difficult to separate the chaff from the wheat in medicine as it is on the web?

Both the curse and the blessing of the web is its accessibility. This means that anyone’s voice can be heard. And it also means that anyone’s voice can be heard. So, we are just as likely to stumble upon drivel as we are on information gold. And what takes time and skill is separating the two into neat piles, one to be ruthlessly discarded, and the other cherished for how it enriches us. To be sure without the web we might not have had access to either, and it is the egalitarian nature of the internet that gives us such a variety of sources in our information diet.

Now, let’s look at medicine. Every day we hear about how much noise there is in the field, and this noise is difficult, if not impossible, to separate from the signal. Some signals are becoming much clearer, and they tell us that by being too egalitarian in medicine, we have likely been causing great harm. Take, for example, PSA and mammography screenings.

The drumbeat of harm associated with these highly non-specific tests and the resultant chase after false positive results, is getting deafening, and rightfully so. Every day we hear that researchers have uncovered a breakthrough mechanism or treatment, and we hear with increasing frequency that a treatment previously thought to be sacrosanct is a bunch of rubbish. What gets lost among all this noise is the possibility of a true breakthrough in disease management or treatment or cure.

Think how hard it is to separate general valuable content from bunk on the web. Now, think of the logs of increase in the levels of difficulty of this task in medicine, where difficult concepts are further shrouded in the opaque cloth of arcane and obfuscating terminology. In fact, it is so difficult, that the class previously designated as the interpreters of this information for the lay public, physicians, are unable to keep up.

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mHealth – Potentially Valuable, But Not Ready For Primetime

mHealth – otherwise known as mobile healthcare – sounds like just what the doctor ordered to help make healthcare delivery cheaper and more effective. And since the Internet today essentially resides in everybody’s pocket, it would seem as though it’s ready to be implemented. But we have what amounts to a “last-three-feet” problem. So I’m not sure mHealth is ready for primetime, mostly because I don’t think our conventional healthcare system is ready or capable of embracing it.

The goal is to have patients wirelessly send appropriate clinical information to their healthcare providers in a timely manner. This would save time-consuming trips to the doctor on their part and, for doctors, ultimately make it easier to retrieve key patient clinical data. Such a system could detect events just before they happen and allow early critical intervention. The problem is that at this point this is just a goal, not reality.

I have looked at a half dozen startups in this space but haven’t made a commitment to fund any of them. In many cases, their technology looks promising, but it isn’t clear how the company would actually generate consistent revenue. Would the healthcare system reimburse mHealth? Would the doctor know how to interpret the flood of real-time data? Would our system drown under a deluge of alerts, many of which resolve naturally? There is a wealth of questions around these issues.Continue reading…

Healthcare Spend at Historic Low

In a rare bit of good news for the Obama administration and budget policymakers,  health care costs increased last year at their slowest pace since the advent of Medicare and Medicaid in the mid 1960s.

The new analysis, released on July 25 by officials at the Centers for Medicare and Medicaid Services, the agency that administers the two programs, showed health care spending grew last year at a “historic” low  3.9 percent rate, which is slightly below 2009’s record-setting low of 4.0 percent. Health care spending as a share of the economy remained stuck at 17.6 percent, a welcome change from most years when it increases its share of total economic activity.

At a time when the White House and congressional leaders are worried about rampant long term growth of the government’s major health care  insurance programs for seniors and the poor, the new data will allow government actuaries to project growth in  Medicare and Medicaid over the next decade will be less than previously feared. This could potentially ease the task of the Obama administration and congressional leaders somewhat when they finally negotiate an agreement for slowing the growth of entitlement programs to help reduce the deficit.

Moreover, CMS actuaries are now saying the cost of insuring 30 million previously uninsured Americans under the president’s signature health care reform bill will add only a sliver to overall spending, and that increase is about half the projected growth rate of a year ago.Continue reading…

Don’t Stop Medical Innovation

The New York Times says “In Medicine, New Isn’t Always Improved.”

Who can argue with this?

“In Dining, New Restaurants Aren’t Always Better.”

Yes, that’s true, too.  But does it mean anything?

The article is about a type of hip that is apparently going to be the focus of a lawsuit.  The story goes that a lot of people wanted the new hip when it came out, because it was thought to be better than the older ones.  Unfortunately, the hip seems to have hurt some people, some of whom may have been better off getting the older one in the first place.

A doctor quoted in the article suggests it’s part of a uniquely American tic.  We want all of the latest and greatest things for ourselves, it seems.  This story is supposed to be a cautionary tale of what can go wrong when we do.

On the other hand, the latest and greatest things don’t appear out of nowhere.  In America, when people demand something, there will be someone who supplies it.

It’s true.  Doctors, researchers, the government, and, yes, for-profit companies, create things.  They invent diagnostic tests and treatments for disease that never existed before.  One reason why the U.S. has a trillion-dollar health care economy is because there are so many people creating so many new things that people can sanely talk about curing – or at least managing – all disease.  This is a good thing.

But all these breakthroughs are a two-edged sword.

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Are Patients Becoming Day Traders?

Let me say first that I am a practicing primary care doctor who is very much focused on patient centered care. Though I cannot go back to being a patient who is unaware about what a doctor does, the terminology she uses, or what the importance of certain test results are, I can empathize with the overwhelming amounts of information, challenges, and stressors patients and families can have in navigating the healthcare system to get the right care. This is the reason I wrote my book.

However, over the past few months I’ve noticed a particularly disturbing trend. Patients are not consulting doctors for advice, but rather demanding testing to force diagnoses which are not even remote possibilities. A little knowledge can be dangerous particularly in the context of little to no clinical experience. Where many patients are today are where medical students are at the end of their second year – lots of book knowledge but little to no real world experience.

More patients are becoming the day traders of the dot.com boom. Everyone has a hot stock tip, only now it is “be sure to ask your doctor for this test” or “ask for this medication because it is the only one that works”. Everyone is an expert with his own suggestion on what should be done. If a medical expert, like a doctor, weighs in and does not agree, then there is a set of patients and doctors who begin to argue that these doctors are out of touch or arrogant.

Hardly.Continue reading…

Vermont’s Bold Experiment

I was delighted to see the lead article in Health Affairs describing Vermont’s new single payer health care financing system. Harvard Professor William Hsiao and his coauthors describe this as a “Bold Experiment” and I couldn’t agree more. It is also a very welcome experiment. For over thirty years I have heard the rhetoric that a single payer system would never work in the United States. For that matter, I have heard that a true market-based system (with vouchers) would never work either. Why not let the states experiment and find out what will and won’t work? Thankfully, the Vermont legislators and Governor Shumlin had the courage to take this leap of faith.

The biggest obstacle to implementation appears to be ERISA, which limits the extent to which states can regulate self-funded plans. Apparently, self-insured employers could object to having their tax payments used to support the plan. But Vermont can apply for an ERISA waiver under terms in the Affordable Care Act and the state hopes to begin its bold experiment in 2015.

As bold as the plan might be, Hsiao et al. might be even bolder in projecting the potential cost savings, which they peg at 25.3 percent. Academics rarely go out on a limb with projections like this that can easily be assessed in a few years time. And academics are rarely so optimistic. I wish I could share that optimism.Continue reading…

Why Cost Cutting Doesn’t Work – And What Will Work

Cutting costs does not cut costs. If we hope to steer health care toward a better cheaper future, we have to wrap our minds around this conundrum: Slashing spending does not necessarily improve the bottom line.

Governments in Ireland and the United Kingdom have come up hard against this conundrum. They have both faced soaring deficits due to the economic downturn, because their tax revenues have fallen at the same time that their costs for unemployment and other kinds of social support have risen.

So they both did what might seem like the sensible thing: They attacked the problem by cutting spending, in the professed belief that such a move would also increase the financial markets’ confidence in the future, and thus pump up the economy, reduce unemployment, reduce the interest the government has to pay on its debt, and increase tax revenues.

Result? Their deficits have grown even larger. Why? Because what economist Paul Krugman likes to call “the confidence fairy” never showed up. The austerity measures tanked their economies even further. Firing a lot of people, it turns out, drives unemployment up and tax revenues down. The worsening debt picture increased the cost of borrowing. Many U.S. states are headed down the same path right now, slashing spending in order to slash deficits, and the U.S. Congress is famously and forever wrangling over the same formula.

Health Care Reform in 2 Short Sentences

Foes of the Patient Protection and Affordable Care Act (PPACA) made a big point of complaining about the length of the bill. Personally, I think that criticism is unfair, because the law deals with a complex industry that’s almost one-fifth of the economy.

But today I read a brilliant two-sentence proposal in the letters section of the Wall Street Journal from David J. Gross, a Florida dermatologist. He was reacting to an article about the extensive cardiac care received by former vice president Dick Cheney.

Before any of Dick Cheney’s heirs get a nickel from his estate, Medicare should be reimbursed for the difference between what it paid out versus what he paid in all these years. This same paradigm should apply to all of us.

(Actually the essence is expressed in just one sentence.)

If we actually implemented that solution it would have significant salutary effects:

* Make Medicare financially viable for the long run
* Improve inter-generational equity
* Instill cost consciousness in Medicare beneficiaries, thus keeping a lid on expenses
* Reduce the need for an estate tax

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The AAFP’s Bold New Valuation Initiative

This morning, the American Academy of Family Physicians, the largest and “purest” of the major primary care societies – the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) are all heavily influenced by sub-specialists – announced that it has convened a national task force charged with identifying new, better approaches to value primary care services.

This initiative is nationally significant for several reasons. By definition, it challenges the methodology used for nearly two decades by the American Medical Association’s Relative Value Scale Update Committee (AMA RUC), which has drastically under-valued primary care services while over-valuing many specialty services. By taking on this effort, it not only announces that the fruits of the AMA RUC’s labors are unacceptable, but also points out that the methodology the RUC uses to value medical services – this is founded on the Resource-Based Relative Value Scale (RBRVS) “input” taxonomy developed by William Hsaio’s team in the late 1980s – is incomplete and outdated. For example, the RUC’s methodology for calculating value doesn’t consider whether a service produced a worthwhile benefit to the patient or society, whether it was evidence-based or even necessary. More on this in a future article.

Next, the task force is not limited to AAFP members, but a wide range of professionals drawn from other primary care medical societies, business, the health plan sector, policy groups and subject matter experts. See the bios here. (I’ve been asked to participate, and will be honored to do so.) In other words, unlike the RUC, this group is more representative of the sectors whose interests it will focus on.Continue reading…

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