Author Archives

John Irvine

Nature vs Nurture

Apr 29, 2017• 4

By SAURABH JHA MD

My wife chooses sides in the nature-versus-nurture war expeditiously. When our children are polite, she credits her nurture. When they’re rowdy, she blames my genes. But the nature-nurture war won’t be resolved anytime soon.

The gene played a significant role in the great Indian epic, the Mahabharata. Karna, abandoned by his mother, Kunti, and raised by a charioteer, was taught warfare by Parashurama, a gifted teacher with a fiery temperament, who despised warriors and only taught Brahmins.

One day, Parashurama was asleep with his head on Karna’s lap. Karna was bitten by a scorpion but did not move, because he did not want to disturb his guru’s nap. Parashurama, who believed that Karna was a Brahmin, seeing Karna’s blood on the ground realized that he had withstood pain which only a warrior could abide. Parashurama cursed Karna that he would forget his knowledge of warfare when he most needed it. Karna later fought for the Kauravas in the Battle of Kurukshetra. Parashurama’s malediction helped Arjuna beat Karna, which sealed the victory for the Pandavas. Neither Karna nor Parashurama knew about the double helix. The gene is an abstraction which has stood the test of time.

Would Repealing the ACA Violate International Law?

Apr 28, 2017• 2

By DAVID INTROCASO and JASON CHUNG

Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.

In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.

This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.

The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.

Can Interactive Group Therapy Boost Productivity in Medicine?

Apr 27, 2017

By DEVON HERRICK

Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?

Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.

Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.

The Return of the Angry Granny State

Apr 26, 2017• 19

By CHARLES SILVER

Texas should call itself The Granny State. That’s because it’s a nanny state in which the public officials who run the place have the values of a tea-totaling, Bible-thumping biddy who knows how God wants everyone to live and can’t resist telling them. No buying liquor on Sundays when people are supposed to be at church. No gambling ever. No whacky-weed for medicinal uses or recreation, even in the privacy of one’s home. No gay marriage, preferably no gays, and no transgender folk deciding which restrooms to use. And, of course, no sex, sex education, birth control, or abortions. Women should have sex only in marriage and then only to reproduce, and those who get pregnant must carry their babies to term, regardless of the consequences for themselves or anyone else.

These religion-inspired policies have served Texans poorly. The state’s maternal mortality rate nearly doubled in just two years after Texas cut its budget for family planning by two-thirds and eliminated funding for Planned Parenthood clinics. It’s now the worst in the developed world, not just in the US. Texas ranks 8^th from the bottom in the frequency of STDs and has the 5^th highest teen pregnancy rate too. Its 35 births per 1,000 girls aged 15-19 are nearly double the national average. Meanwhile, Colorado and other states have achieved miraculous reductions in teen pregnancy rates and abortion rates by providing young women with long-acting contraceptives, like implants and IUDs. If Texas is following God’s plan, then God’s plan is a bust.

Now Granny is once again sticking her nose where it doesn’t belong. Currently before the Texas legislature is Senate Bill 25, which would eliminate the wrongful birth cause of action that the Texas Supreme Court recognized four decades ago in Jacobs v. Theimer. The facts were as follows. While traveling, Dortha Jacobs became ill. Upon returning home, she consulted a physician, Dr. Louis Theimer, who discovered that she was newly pregnant. Fearing that the illness was rubella—also known as the German measles—Jacobs asked Dr. Theimer if there was reason for concern. Rubella can injure a gestating fetus severely. Dr. Theimer told her not to worry, but he did so without performing an available diagnostic test. In fact, the disease was rubella and the child “was born with defects of brain, speech, sight, hearing, kidneys, and urinary tract,” among others. The medical expenses were extraordinary.

The Fairy Tale of a Non-Profit Hospital

Apr 25, 2017• 22

By NIRAN AL-AGBA, MD

Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations. 3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax. An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.

The idea of exempting nonprofits from paying taxes in the first place is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand. As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question.

The Sad Myth of the Direct to Consumer Startup

Apr 24, 2017

By LISA SUENNEN

Last week I had a startup entrepreneur come to me with an idea about how to “pivot” his company strategy. The company, which had begun as a medical device company but couldn’t quite find it’s market, was considering re-emerging as a consumer-focused digital medical device company in an adjacent market. The idea was to create a device to measure a serious medical condition and market it to consumers directly. Their plan was to target mothers who would be paranoid enough to spend money on medical devices to diagnose an issue in their children.

Imagine my heavy sigh.

Ever the heart-breaker, I had to tell this person that this strategy did not make any sense to me. As his target market representative du jour, I mentioned that there is no world in which I would trust myself to diagnose a major medical problem. Rather, if I even suspected a hangnail I would rush my precious princess straight to the doctor, do not pass Go, do not pay iTunes fees.

If I Had More Time, I Would Have Written a Shorter Blog Post

Apr 23, 2017

By ROBERT MCNUTT

I don’t know why, but even as a young person I never could make sense of the saying, “seeing is believing”. Seeing, vision, is nothing more than a data collection instrument, not an arbiter of insight. I saw my wife frown at me the other day, for example, after I claimed to have washed the dishes so thoroughly that no spot of grease could be left behind. I have made this claim before and been incorrect, so the frown, the data, triggered an anticipation of being rebuffed. However, nothing of that sort followed. I asked, Why the frown?” She responded, “I just cut my finger”. The frown was obvious, the cause unclear. I believed I was about to be reprimanded and missed the chance to notice her accident. This story suggests that a truer aphorism might be, instead, then, that “believing is seeing”.

A Modest Health Care Economics Experiment to Fight Rising Costs

Apr 20, 2017• 34

By HAYWARD ZWERLING, MD

Healthcare providers, medical institutions, local pharmacies and pharmaceutical companies generally set the price of their products/services well above the payment they expect to receive from all insurers. These healthcare vendors set their fee schedule at 150%, 200% or 1,000% of the maximum payment they expect to receive from their most generous payor.

Here in Massachusetts, when a healthcare product or service is consumed and the patient has health insurance, the vendor submits a bill to the insurance company who specifies the “allowed fee,” which is considerably less than the “billed fee,” and the vendor “writes off” the balance of the “billed fee” from their books.

For example, I recently had some blood tests done at Quest Diagnostics. Quest Diagnostics sent a bill to my insurance company for $660. The “allowed payment” was $110, so Quest wrote-off $550 and the “allowed payment” of $110 was divided between me and my insurance company.

Al Lewis Talks about Al Lewis

Apr 18, 2017• 2

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The Strange Making of the “Marketplace Stabilization Rule”

Apr 17, 2017• 1

BY DAVID INTROCASO

On April 13 CMS published the agency’s final “market stabilization” rule. The proposed rule was summarized by THCB’s editors on February 15, the day it was published, and on March 22 THCB published my essay in which I noted CMS provided no evidence any of the proposed reforms would actually stabilize the state marketplaces. The final rule, ostensibly a carbon copy of the proposed, finalizes the six proposed changes without, again, providing any evidence these changes will stabilize the markets by increasing enrollment and issuer participation.

Briefly, the final rule will reduce the 2018 enrollment window from three months or to six weeks, or from November 1 to December 15. The rule narrows the definition of guaranteed availability by allowing issuers to apply re-enrollment payments to outstanding debt. The rule will require 100 percent verification for enrollees’ attempting to acquire insurance during a Special Enrollment Period (SEP) and places other payment, eligibility and exceptional circumstances restrictions on SEP enrollment. The rule finalizes an increase in de minimus variation from +/- 2 percent to -4/+2 percent except for bronze plans which increases to -4/+5 percent. The rule will allow states to determine plan network adequacy or make a determination using an issuer’s accreditation status. The rule finalizes a reduction from 30 to 20 percent of plan providers being defined as an Essential Community Provider (ECP). For plans that cannot meet the 20 percent determination, CMS will allow for a narrative explanation.
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