Author Archives

John Irvine

It Begins

Jan 3, 2017• 2

By STEVEN FINDLAY

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For the second time in a decade, a president and Congress will undertake a large-scale effort to re-engineer the health care system.

Politics and debate over policy are not the primary cause of this continued upheaval. It is our patchwork, Rube Goldberg-like system, developed ad hoc over 50 years.

As THCB readers know, we have an insurance and care delivery system that works less well—in terms of public health, coverage, patient outcomes, and cost—than health care in most of the rest of the developed world.

And, things are getting worse. To wit: rising death rates among middle-aged, low- and middle-income white Americans; the unchecked rise in obesity and preventable chronic diseases and opioid addiction; and woefully slow progress to reduce medical errors and improve patient safety.

Here’s What Won’t Happen in 2017
(And What Will)

Jan 2, 2017• 1

By PAUL KECKLEY

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In the political drama surrounding the new administration, healthcare is certain to take center stage as the 115th Congress convenes tomorrow and Donald Trump is sworn in as our 45th President and Chief Executive January 20. As it turns out, healthcare was a major issue in Campaign 2016, especially with Clinton-Sanders followers who wished expansion of coverage and a vocal minority of GOP voters who liked the promise of Repeal and Replace. Now it’s time to govern.

For the new Congress and administration, governing healthcare will play out against a testy backdrop: it will not be easy.

The Nation is Divided about the Affordable Care Act (HR3590): Only one in four Americans and one in two Republicans surveyed after the election wants the ACA repealed. By contrast, 30% want it expanded and 19% want it to remain as is, (Kaiser Family Foundation Poll December 28, 2016). Elements of the law are popular, like protections against denial of coverage due to pre-existing condition and continuation of coverage for young adults under 26 on their parents’ policy. But the individual mandate became a rallying cry for opponents who labeled it “government run healthcare” and partisans who tagged it ‘Obamacare’ voting to repeal it more than 60 times in the House. Objectively, for the past four years, the ACA has been shorthand for a debate about health insurance coverage and premium costs. The law imposed restrictions on how insurers operate and expanded coverage via Medicaid expansion and subsidies for those between 100 and 400% of the federal poverty level. Access increased–20 million are now covered that weren’t before—and premiums went up for everyone because the law imposed restrictions on how plans were required operate. Ironically, the insurance reforms are in Title I of the ACA “Quality, Affordable Health Care for all Americans”; delivery system reforms that address gaps in quality, care coordination, healthcare workforce innovation and unnecessary care are covered in the other 9 titles that got little attention from media, political pundits and politicians. Nonetheless, the ACA divides America though most know little about what’s in it.

Millennials: The Greater Generation?

Dec 30, 2016• 11

By JIM PURCELL

screen-shot-2016-12-30-at-9-44-14-am In 1991, William Strauss and Neil Howe wrote the book Generations. It was recognized then and today as remarkable. The authors posit the history of America as a succession of generational biographies, beginning in 1584 and proceeds to the children of 1991. Their theory was that each generation belongs to one of four types, and that these types repeat sequentially in a fixed pattern.

In a (now) fascinating passage in the Preface, they discuss the Boomer Generation, saying (remember it’s 1991) that “You may feel some disappointment in the Dan Quayles and Donald Trumps who have been among your first agemates to climb life’s pyramid, along with some danger in the prospect of Boomer Presidents…farther down the road.” Later in the same paragraph: “Perhaps you already sense that your Boomer peers, for all their narcissism and parallel play, will someday leave a decisive mark on civilization quite unlike anything they have done up to now.” Spooky huh, as we embark on a Trump Presidency?

Generations, even that early, suggests that Millennials will be a uniquely impactful generation, mostly in a positive way, much like what they call the “GI” Generation and most of us call the “Greatest Generation.” Well… they fall in the same ordinal slot as the Greatest Generation given the following dates of birth for each generation: Greatest Generation (1901-24); Silent Generation ((1925-43); Boomer Generation (1943-60); Gen-X (1961-81); and Millennials (1982-2000). They have Boomers starting earlier than the traditional view, a position I very much agree with having been born in 1945.

Earlier this month, an article appeared in the Boston Globe titled Millennials Aren’t Lazy, They’re Workaholics. That didn’t quite fit with my impression, so I started digging a bit. I of course went on line and found a definition in the Urban Dictionary:

Special little snowflake.

Born between 1982 and 1994 this generation is something special, cause Mom and Dad and their 5th grade teacher Mrs. Winotsky told them so. Plus they have a whole shelf of participation trophies sitting at home so it has to be true.

They believe themselves to be highly intelligent, the teachers and lecturers constantly gave them “A”‘s in order to keep Mom and Dad from complaining to the Dean. Unfortunately, nobody explained to them the difference between an education and grade inflation so they tend to demonstrate poor spelling and even poorer grammar.

Internet Self-Diagnosis: Mapping the Information Seeking Process

Dec 29, 2016• 2

By SUSAN PEREZ

We’ve all been there. It’s early morning, and you wake up feeling groggier than usual, sensing the onset of a sore throat and a runny nose. Before crawling out of bed, you grab your smart phone and, naturally, Google “groggy sore throat runny nose symptoms.” Hundreds of results pop up, suggesting various illnesses and links to seemingly promising remedies. How could anyone filter through page after page of links, ranging from everyday allergies to deadly diseases?

Many of our health choices are made outside the doctor’s office. The simple decision of whether symptoms are severe enough to warrant visiting a healthcare provider is one of them. For some patients, that decision is easy, because regardless of the severity of symptoms, from a simple cough to leg pain, getting in to see a healthcare provider is easy. Unfortunately, many people still struggle to find a healthcare provider, get an appointment, and/or obtain transportation. These individuals are left to turn to other health information resources, such as the Internet, to determine whether their symptoms are severe enough to navigate these barriers.

The “digital divide” has become a catchphrase for how differences in educational, social, and economic backgrounds can affect access to web-based tools and services, as well as the general ability to use the Internet.

That divide has serious healthcare consequences: Though the web is not intended to replace traditional medical care, it may offer one of the few available sources of information for those with limited access to health services. While patients who regularly visit a provider are privy to the diagnostic processes of medical professionals, web-based tools may be critical in weighing the severity of symptoms for those with fewer resources and less access. Continue reading…

The Art of the Deal: Coming
to Rx Prices Soon

Dec 28, 2016• 7

By GARY MENDOZA

screen-shot-2016-12-28-at-2-21-40-pm During the campaign, President-elect Trump said “(w)hen it comes time to negotiate the cost of drugs, we are going to negotiate like crazy.”

While the President-elect’s pronouncements can’t always be taken at face value, this one should be.

In its December 7, 2016 prescription drug report to Congress, HHS reported Medicare (Parts B and D) and Medicaid Rx expenditures equaled $165.5 billion in 2014. Total 2014 retail and non-retail Rx spending was $424 billion.

HHS also reported that Rx spending “has been rising more quickly than overall health care spending . . . [and in] recent years, growth in prescription drug spending has accelerated considerably”.

If the reported annual rate of growth in 2014 (12%) holds for 2015 and 2016, Medicare/Medicaid’s Rx spending and total Rx costs in 2016 will exceed $200 billion and $500 billion, respectively.

As fiscal pressures to control healthcare costs build, Rx prices may be the ripest big ticket item on the table.

As the Trump Administration looks for bipartisan support for an ACA replacement, Rx prices could also provide some glue.

Dithering: How MedPAC Perpetuates Failed Managed care programs

Dec 27, 2016• 7

By KIP SULLIVAN, JD

The Medicare Payment Advisory Commission (MedPAC) is supposed to give Congress good advice about Medicare. MedPAC is good at telling Congress that the managed care experiments Congress keeps foisting on Medicare are not saving money. But MedPAC is terrible at telling Congress why these experiments are failing and whether they can be salvaged. The Medicare Advantage program is the longest-running example of MedPAC’s chronic inability to explain to Congress why a managed care program isn’t working and what should be done about it. The ACO and MACRA programs are two other examples.

MedPAC’s meandering discussion about converting Medicare into a voucher program, which began three years ago, illustrates the problem. I’ll focus on that discussion in this post.Continue reading…

National Health Expenditures Continue to Accelerate in 2015. What Does That Mean?

Dec 26, 2016• 18

By ANISH KOKA, MD

In 2009 a youthful Barack Obama addressed a joint session of congress on health care on a cold fall evening. The country was still recovering from the great financial crisis, and the new President was now attempting to turn the nation’s eye to health care. As he had done many times before, Obama spoke powerfully of the tragedy of millions of citizens with ‘no access’ to health care, but spoke practically of the unsustainable and untenable economics of health care.

“Finally, our health care system is placing an unsustainable burden on taxpayers. When health care costs grow at the rate they have, it puts greater pressure on programs like Medicare and Medicaid. If we do nothing to slow these skyrocketing costs, we will eventually be spending more on Medicare and Medicaid than every other government program combined. Put simply, our health care problem is our deficit problem. Nothing else even comes close. Nothing else. (Applause.)

Now, these are the facts. Nobody disputes them. We know we must reform this system. The question is how. “

These were the indisputable facts, he said. ‘Nobody disputes them’.Continue reading…

The Perils of Precision Medicine

Dec 26, 2016

By MERCEDITAS VILLANUEVA , MD

When The White House announced their Precision Medicine Initiative last year, they referred to precision medicine as “a new era of medicine,” signaling a shift in focus from a “one-size-fits-all-approach” to individualized care based on the specific characteristics that distinguish one patient from another. While there continues to be immense excitement about its game-changing impact in terms of early diagnoses and targeting specific treatment options, the advancements in technology, which underlie this approach, may not always yield the best medical results. In some cases, low cost approaches, based on sound clinical judgment, are still the better option.

For example, tuberculosis (TB) is an infectious disease that continues to pose global burden with 9.6 million new cases and 1.5 million deaths reported in 2014 alone. The large toll is partly due to lack of effective treatments (particularly for drug-resistant cases) but also due to delays in diagnosis. One might think that precision medicine technology leading to improved diagnosis would be effective at minimizing the related death toll but we shouldn’t automatically assume that. It turns out that sometimes the latest technological advancements can be so sensitive that we detect organisms that are not causing disease.
Continue reading…

Do Women Make Better Doctors Than Men? Part II

Dec 22, 2016• 8

By ASHISH JHA, MD

Ashish Jha Our recent paper on differences in outcomes for Medicare patients cared for by male and female physicians has created a stir. While the paper has gotten broad coverage and mostly positive responses, there have also been quite a few critiques. There is no doubt that the study raises questions that need to be aired and discussed openly and honestly. Its limitations, which are highlighted in the paper itself, are important. Given the temptation we all feel to overgeneralize, we do best when we stick with the data. It’s worth highlighting a few of the more common critiques that have been lobbed at the study to see whether they make sense and how we might move forward. Hopefully by addressing these more surface-level critiques we can shift our focus to the important questions raised by this paper.

Correlation is not causation

We all know that correlation is not causation. Its epidemiology 101. People who carry matches are more likely to get lung cancer. Going to bed with your shoes on is associated with higher likelihood of waking up with a headache. No, matches don’t cause lung cancer any more than sleeping with your shoes on causes headaches. Correlation, not causation.

Knowing What Not to Do

Dec 22, 2016• 23

By JIM PURCELL

“The essence of strategy is choosing what not to do.” Michael Porter.

It is so often the case that organizations try to do things they should not do. Call it irrational exuberance; getting out in front of the curve; or a bridge too far. Hospital systems are examples of that. Already large, complex organizations doing incredibly challenging things with billions of dollars flowing through their systemic blood vessels, they are understandably tempted to do more. They always are. That is the inevitable urge of active hospital board members and ambitious executives. Do more; not do less. After all, who arrives to such an exalted position to do less?

Their collective corporate eye is cast toward health insurers who have been called bloated and inefficient; dinosaurs; dim witted at best. The President of the United States, no less, disparaged insurers while promoting the ACA, labelling them the “villains” of the healthcare system. Speaker Pelosi called them “immoral.” How difficult can it be to do health insurance better than the insurers have done it? Should be easy for people as smart as those who run complex healthcare delivery systems.

“Hospitals think this is a way to cut out the middle person, tailor care more closely and save a lot of extra money, but there’s a history to this and it generally doesn’t work,” said Howard Berliner, a visiting professor of health policy at NYU. “It sounds easy, but it winds up being incredibly complicated.”