By UWE REINHARDT

Consider the poor bloke depicted below. He lies, exhausted, on a sand dune in the Sahara desert, literally dying of thirst.

Along comes a camel caravan, evidently with a group of tourists in the lead. The caravan is bound to be loaded with water.

Surmising that the dying man’s demand for water is bound to be highly price-inelastic (the economist’s jargon for “insensitive to price”), one of the camel riders jumps off his camel and waves a bottle of water in front of the dying man’s face, asking him: “What would you give me for this bottle of water?”

“Everything I own,” moans the dying man, knowing that none of his assets would be worth anything to him unless he got water soon.

“Done deal,” says the tourist, beckoning one of his fellow travelers, a lawyer, to draft up the necessary documents, which the thirsting man quickly signs in return for that life-saving bottle of water.   

What might we call this hypothetical transaction and the price the tourist extracted from the dying man for that life-saving bottle of water?

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BY AL LEWIS

There is a saying: “In wellness, you don’t have to challenge the data to invalidate it.  You merely have to read the data.  It will invalidate itself.” Indeed, if there is one thing you can take to the bank in this field, it’s that articles intending to prove that wellness works inevitably prove the opposite. Another saying is that the biggest enemies of Ron Goetzel and his friends (the Health Enhancement Research Organization, which is the industry trade assocation) are facts, data, arithmetic, and their own words.

And Mr. Goetzel, writing in this month’s Health Affairs [behind a paywall], is Exhibit A in support of the paragraph above.  The “overscreening today, overscreening tomorrow, overscreening forever” gravy train of the wellness industry is officially dead. (They can still screen employees intermittently, according to guidelines recommended by the US Preventive Services Task Force, but no wellness vendor ever got rich by doing that.)

It did not die because of his conclusion that companies with lower employee risk factors spend more than companies with higher employee risk factors. That by itself would be worthy of a headline, of course, since it’s quite at variance with the massive savings shown in the Koop Awards he gives to his friends.  But there is much, much bigger news, though in this case he “buried the lead,” in a sleight-of-hand that he knew Health Affairs‘ peer reviewers wouldn’t notice.Continue reading…

By RYAN MARLING

American football is rich with statistics and advanced analytics meant to depict success in specific facets of the game. Once the dust settled after the New England Patriot’s breathtaking Super Bowl comeback against the Atlanta Falcons, I couldn’t help but draw parallels between healthcare—specifically, diabetes, also rich with metrics and indicators—and the approach of legendary football coach, Bill Belichick.

For years, patients with diabetes have relied on their glycated hemoglobin (HbA1c or hemoglobin A1c) levels to assess their success in managing their diabetes. An HbA1c score is known in the field as a steadfast indication of a person’s average plasma glucose concentration over a three-month period. This metric gives patients and their care team an idea of how well their blood sugar is being managed. 

This approach, however, is being reconsidered as healthcare practitioners recognize that the goal of diabetes management should not be to obtain an ideal HbA1c score, but rather to reduce the risk of diabetes-related complications that have direct impact on patients’ day-to-day lives and long-term well-being. In fact, a recent study suggests that strict control of one’s HbA1c does not significantly impact one’s risk of diabetes-related complications.

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DAVID INTROCASO

It is well recognized that over the past several decades US prisons and jails have become the nation’s largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness. 1  Leaving aside the question whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percentage of mentally ill inmates is to place them in solitary confinement. 2  This means how we treat a significant percent of the mentally ill in this country is to torture them.

In the editors’ introduction to Hell is A Very Small Place, Voices From Solitary Confinement, a chapter that should be required reading for all health care students, Jean Casella, James Ridgeway and Sarah Sourd note that on any given day between 80,000 and 120,000 men, women and children are held in solitary confinement in US prisons and jails. 3  One-third to one-half of those placed in solitary confinement already suffer mental illness that is frequently accompanied by developmental disabilities, physical disabilities and substance addictions.  

A similar percent of all others placed in isolation will develop psychiatric symptoms, if not complete decompensation, particularly if they are confined for an extended period of time.

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By ALAN PITT

Several months ago I had a conversation with Dr. Robert Spetzler, the Director of the Barrow Neurological Institute. During our interview Dr. Spetzler mentioned that the patient needs to become captain of their own ship. I agree. Although most of us (as patients) would like someone to step in and care for us when we’re sick, rising costs and limited providers make it impossible for the healthcare industry to meet America’s expectations for care. Healthcare needs patient partners.

But in all fairness, I thought to ask a patient what they need. So, with the start of 2017, I thought to ask turned to someone who deals with her care everyday, my mother.

Sheila Pitt is an Art Professor at the University of Arizona. In 2008 my mom suffered a fall from a horse and became a quadriplegic. Since then she has gone back to work teaching and continues to make art with a new process she developed using the abilities left to her. In the past I wrote about my perspectives on her accident. I thought I’d discuss my mother’s journey in healthcare.

Alan: So, Mom, can you tell me when you first realized you were quadriplegic?

Sheila: Yes, I can. I was in my hospital bed having just returned from the surgical floor when one of the nurses referred to me as a quad. And—not to me but to someone else—they said, get this quad ready for whatever the procedure was. I was shocked. I had no idea I was a quad. No one had talked to me about it. No one had explained what that was about. And it was like I wasn’t there. They were talking about me as a quad and I was really quite shocked that they did that. But I realized I must have been a quad.

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By PETER PRONOVOST, MD

Her voice cracked with strain. I could imagine the woman at the other end of the line shaking, overcome with remorse about the hospital where her husband had had esophageal surgery. Might he still be alive, she asked me, if they had chosen a different hospital?

The couple had initially planned to have the procedure done at a well-known medical center, but when she went online to do her homework, she discovered that the hospital’s patient safety scores were poor. Another hospital in her community had stronger patient safety ratings, so they decided to have the procedure there.

It made sense. Why wouldn’t they go to a safer hospital?

What she didn’t know was that multiple studies over several decades have shown outcomes are better when procedures are handled by surgeons and hospitals with higher volumes, and while the well-known hospital had performed the procedure her husband needed many times during the previous year, the hospital they chose had done one.

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By DEVON HERRICK

Republicans are having a hard time agreeing on how and when to repeal Obamacare. The Patient Protection and Affordable Care Act (ACA) is difficult to unravel because it was designed to alleviate a problem too costly for the government alone to fix. The health care law was passed to make medical care more accessible for low-income Americans and those with pre-existing conditions. This was to be done largely by socializing the costs and spreading the burden among a much broader segment of the healthy population. This is not unlike a pyramid scheme, where a broad base of people at the bottom get ripped so a few at the top can benefit.

Republicans have it within their power to use a process known as budget reconciliation to repeal Obamacare provisions that involve the budget, with a simple majority vote. For example, Republicans can repeal the taxes, fees and appropriations that fund the ACA. The individual and employer mandates, with associated penalties, can also be repealed. What Republicans cannot do is repeal the costly insurance regulations that drive up premiums for most people. That would require the help of perhaps a dozen skeptical Democrats.

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 By PAUL KECKLEY

Lieutenant colonel Justin Constantine USMC

Through the years, I’ve had the honor of speaking to groups after they heard from notables like Michael J. Fox, Sammy Hagar, Jeff Immelt, U.S. Secretaries of Health Tommy Thompson and Mike Leavitt, Warren Buffet and others. They’re the headliners and I usually follow them with a less celebrated presentation about the current issues and future in healthcare. 

Earlier this month, in Arizona, I spoke to 3M’s annual healthcare conference following Lt. Colonel Justin Constantine, a Marine who served from 1997-2013. Justin’s story is profound: he was plying his trade as a military lawyer in the Al Anbar province of Iraq on October 18, 2006 when a sniper’s bullet tore through his head. After an emergency tracheotomy by Navy Corpsman George Grant, scores of surgeries and years of treatment, he survived and now shares his story as an inspirational speaker, crediting the Military and Veterans Health Systems for saving his life. 

His message was riveting: Leaders lead. Never give up. Don’t be afraid. His scarred face and slurred speech commanded the rapt attention of the 250 in the audience. As he concluded, we all stood in a spontaneous expression of appreciation for this man, his message and his courage. 

Later that day, he shared more about his decade-long climb experience as we traveled together back east. And through this week, I found myself reflecting on his ordeal and the roles of our Military and Veterans systems about which I confess I’d given little thought prior. 

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By MICHAEL TURPIN

I grew up during the last great age of Jurassic parenting.

We called our Dad “T-Rex” because he was the ultimate alpha predator with a big mouth, sharp teeth, limited peripheral vision and small arms that prevented him from doing any housework. His home was his castle.

Our dining room table was his bully pulpit, and fact-checking was an act of sedition, prohibited when he was on a roll. On occasion, a courageous teen would put his college education to work to question my father’s draconian position on the war in Vietnam (“Bomb the NVA back into the Stone Age”) or social protest (“America, love it or leave it”). My father would listen incredulously and then ruthlessly suffocate the nascent rebellion like a banana republic dictator.

My father is no Archie Bunker. At 86, he’s lost a step and repeats himself, but he still understands Keynesian economics. He’s a tried-and-true carnivore capitalist who borders on being libertarian. He has an IQ of 170, and in his heyday he was the regional CEO of a large ad agency. But he has major blind spots and a black-and-white view of the world. His reptilian brain is in fear mode thanks to Fox News and a world that has been reduced to a dozen meds and 3,000 square feet. Before the election, he was angry—always interpreting any action by Obama as a sign of a decline in the values and ethic that made America great. His contradictions would come fast and furious:

“No, I don’t want immigrants. Oh, yes, I do love my immigrant caregivers.”

“I hate socialized medicine, but I love Medicare and don’t want to pay more for it.”

“Bush Jr. was an idiot, but Obama is worse.”

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JIM BUTLER

When is the last time anyone received an estimate of the cost of a healthcare service upfront?  With premiums and deductibles going up thousands of dollars a year, patients have a need and a right to know the cost of any nonemergent healthcare service to help them make an informed decision.

Meanwhile, the healthcare industry, backed by its powerful lobby and the many politicians it seems to control, obstinately clings to a status quo where we are all kept guessing about the cost of our healthcare.

In June of 2015, a law was passed in Ohio that sought to upend that status quo.  Starting January 1, 2017, the Ohio Healthcare Price Transparency Law requires that patients in Ohio must receive a good-faith estimate of the cost for anticipated healthcare services they are scheduled to receive.  Emergencies are obviously excluded, including hospital admissions for acute issues.  The estimate must provide the amount to be charged, the insurance share and the patient share.  Straight-forward enough one would think. 

Unfortunately, over the year and a half since the Ohio Healthcare Price Transparency Law was passed, the healthcare lobby (led by the Ohio Hospital Association) has vigorously sought to kill the law rather than prepare for its implementation. 

Mirroring honed strategies utilized to defeat transparency laws in multiple states, the healthcare lobby claims it really believes in transparency, but offers disingenuous excuses as to why true transparency is “impossible” to provide.  It offers to support the creation of some difficult-to-navigate and nebulous website, or to provide estimates for only a small number of services or only upon formal request.

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