By ASHISH JHA, MD

About a year ago, Yusuke Tsugawa – then a doctoral student in the Harvard health policy PhD program – and I were discussing the evidence around the quality of care delivered by female and male doctors. The data suggested that women practice medicine a little differently than men do. It appeared that practice patterns of female physicians were a little more evidence-based, sticking more closely to clinical guidelines.  There was also some evidence that patients reported better experience when their physician was a woman.  This is certainly important, but the evidence here was limited to a few specific settings or in subgroups of patients. And we had no idea whether these differences translated into what patients care the most about: better outcomes. We decided to tackle this question – do female physicians achieve different outcomes than male physicians. The result of that work is out today in JAMA Internal Medicine.

Our approach

First, we examined differences in patient outcomes for female and male physicians across all medical conditions. Then, we adjusted for patient and physician characteristics. Next, we threw in a hospital “fixed-effect” – a statistical technique that ensures that we only compare male and female physicians within the same hospital. Finally, we did a series of additional analyses to check if our results held across more specific conditions.

We found that female physicians had lower 30-day mortality rates compared to male physicians. Holding patient, physician, and hospital characteristics constant narrowed that gap a little, but not much. After throwing everything into the model that we could, we were still left with a difference of about 0.43 percentage points (see table), a modest but clinically important difference (more on this below).Continue reading…

By DAN ORENSTEIN

On December 7, 2016, the United States Senate approved the 21st Century Cures Act by an overwhelming margin. Having already passed the House with similarly broad bipartisan support, it now goes to President Obama for signature. Several years in the making, the Cures Act is broad and sweeping legislation that covers many topics, mostly on streamlining and accelerating the discovery of new drugs and medical devices. It includes provisions to improve mental health and substance abuse treatment, and to improve patient access to new therapies, among many other areas covered by the Act.

The Act also includes several provisions that will help accelerate the work of health information technology (HIT) companies and providers working to use healthcare data and information to improve outcomes, reduce variations in care, and better coordinate care delivery. These provisions establish programs and oversight to promote health information interoperability and prohibit information blocking practices.

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By LEONARD D’AVOLIO

Recently, a great op-ed published in The Wall Street Journal called “Turn Off the Computer and Listen to the Patient” brought a critical healthcare issue to the forefront of the national discussion. The physician authors, Caleb Gardner, MD and John Levinson, MD, describe the frustrations physicians experience with poor design, federal incentives, and the “one-size-fits-all rules for medical practice” implemented in today’s electronic medical records (EMRs).

From the start, the counter to any criticism of the EMR was that the collection of digital health data will finally make it possible to discover opportunities to improve the quality of care, prevent error, and steer resources to where they are needed most. This is, after all, the story of nearly every other industry post-digitization.

However, many organizations are learning the hard way that the business intelligence tools that were so successful in helping other industries learn from their quantified and reliable sales, inventory, and finance data can be limited in trying to make sense of healthcare’s unstructured, sparse, and often inaccurate clinical data.

Data warehouses and reporting tools — the foundation for understanding quantified and reliable sales, inventory, and finance data of other industries – are useful for required reporting of process measures for CMS, ACO, AQC, and who knows what mandates are next. However, it should be made clear that these multi-year, multi-million dollar investments are designed to address the concerns of fee-for-service care: what happened, to whom, and when. They will not begin to answer the questions most critical to value-based care: what is likely to happen, to whom, and what should be done about it.

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By ART CAPLAN

I just finished my required training about the protection of patient privacy.  Every employee of New York University Langone Medical Center must take an online course and pass an admittedly not very difficult quiz as to our duties regarding patient privacy.  All other American medical centers have the same requirement.  I passed my quiz.  But, despite my certification, I think the effort to protect privacy in health care is a lost cause.  It is time to admit that privacy in health care is dead.  Confessing that privacy has passed on, while reporting a death is often very sad, has many benefits.  Not only is the continued effort to ensure privacy protection futile, it costs a lot of time and money, undermines trust in the health care system, causes confusion that interferes with family needs and, most importantly, likely gets in the way of giving greater benefit to the sick, soon to be sick and those who are not yet born but who will also become ill.

Much of the required teaching in the United States about privacy involves learning a bit about the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The Federal Office for Civil Rights of the Department of Health and Human Services enforces the law that protects the privacy of health information that could identify a particular patient such as addresses, phone numbers, email address and medical record numbers.  I know from my training that hospitals and health care institutions must report any breach of information going to someone not providing care to a patient or paying for that care. 

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By JIM PURCELL

It has happened.  For the first time, consumers are purchasing more on line than in stores.  Even Black Friday 2016 with its emphasis on traditional shopping saw more people buying on line than in stores (44% compared to 40%).  Mobile phone sales on Cyber Monday, at $1.07 Billion, were up 34% over last year, and Cyber Monday sales exceeded Black Friday’s sales according to Adobe Digital.  Personally, I would rather chew off my right pinkie than venture to a mall on Black Friday, but I did shop online taking me two minutes, without moving from my desk.

The traditional consumer shopping world is changing at light speed, and this dramatic sea change is turning shopping malls inside out, literally and figuratively.  In the process, Amazon has eaten the collective lunches of Macy’s, Penny’s, Kohl’s, and even Wal-Mart.

By way of example, Amazon offers a purchasing experience that makes use by smart phone an obvious choice for Millennials who must be served if businesses are to survive the next two decades. On line price shopping is quick and incredibly convenient; price comparisons are easy; customer service is superb; and such things as Amazon Prime are eliminating shipping costs and speeding delivery.  Returns are easy, requiring only some scotch tape and a stop at a UPS drop box.  What’s not to like in this age of little spare time?

Consequently, brick and mortar stores are in serious jeopardy and are like deer in headlights, reminiscent of companies such as Blockbuster, Kodak, and Xerox, which fell prey to disruptive technologies, products, and trends.  Only time will tell if traditional stores will survive, but the smart money is not investing in malls these days.Continue reading…

By DAVID KENDALL

It’s very possible that the pejorative “Obamacare” could become the even more pejorative “Trumpcare” in a very short period of time. That is because Trump’s and the GOP’s promise to repeal Obamacare — the Affordable Care Act (ACA) — has already hit a snag called reality.

Reports are now circulating that the much-promised repeal of the health care law (60 plus House and Senate votes since 2010) won’t take effect until at least 2019, after the mid-term elections. The excuse is that it’ll take that long to figure out an alternative and get it into place. But congressional calendars and political expedience have nothing to do with the health care market. And without action early in 2017, the health insurance exchanges could collapse in 2018 or sooner — leaving millions without insurance, millions more without protections from pre-existing conditions, and possibly millions more cursing Trumpcare. The only constructive solution is to repair the ACA before, ironically, repealing it and then replacing it with a brand new, untested experiment in 2019.

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By STEVEN FINDLAY

President Obama signed the 21^st Century Cures Act into law this week.  It’s the largest piece of health legislation since the Affordable Care Act.   No doubt you’ve heard or read that—and it’s true. 

But while the legislation was three years in the making and much hyped, it became the best recent example of that old saying that passing federal laws is akin to sausage making:  You don’t really want to watch what goes into it.

(An aside:  I made venison and bacon sausages from scratch for the first time this year and can attest to the “visceral” nature of that exercise.) 

There’s something for almost everybody in this new law.   That’s one reason it was the most lobbied health bill since the ACA.  In particular, the pharmaceutical and medical device industries were big winners.  Fifty-eight drug companies, 24 device companies and 26 biotech companies lobbied the bill, spending close to $200 million altogether, according to a Kaiser Health News analysis of lobbying data compiled by the Center for Responsive Politics.

What they got:  a big nudge to the FDA to find ways to approve drugs and devices faster.

For example, one change in the law allows FDA to accept as proof of safety and effectiveness less rigorous clinical trials, as well as other types of studies and data—both for the initial approval of drugs and to authorize new uses for drugs already on the market. 

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By KIP SULLIVAN, JD

What would you do if you were a member of the Medicare Payment Advisory Commission (MedPAC) and you were told Medicare Advantage and Medicare’s ACO programs are losing money and there’s no way to determine why they’re losing money? That is what happened over the course of two MedPAC meetings, one in October and another in November. At the morning session of the October 6, 2016 meeting, MedPAC staff reported data on the Pioneer and MSSP ACO programs indicating that the two programs together raised Medicare’s costs slightly in 2015. And at the morning session of the November 3, 2016 meeting, staff reported that Medicare Advantage (MA) raised Medicare costs by 5 percent in 2016 (which is down from 14 percent in 2009) and, moreover, that it’s extremely unlikely anyone will ever know why MA plans and ACOs are raising costs.

If you were a commission member, wouldn’t you at least inquire why the staff thinks it’s impossible to determine the causes of the MA and ACO programs’ failure to cut costs? And if you confirmed that it really is impossible to know why they’re failing, wouldn’t you say it’s high time to terminate those programs? Not one of the 16 commission members present at those meetings did that. Many of the commissioners expressed frustration with the poor performance of the ACO programs (for some reason they spared the MA program from similar criticism). But not one demanded to know why the commission knows so little about what goes on inside HMOs, PPOs and ACOs, nor why the staff thinks the information vacuum will go on forever. Surprisingly, two commissioners (Buto and Gradison) did suggest it was time to terminate the MSSP ACO program. But they received no support from any other commissioners or staff.Continue reading…

By NIRAN AL-AGBA, MD

U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014.  However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply.  Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate.  It is a well-known and reproducible statistical relationship that holds true throughout the world.  In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.

Headlines last week highlighted how much these unexpected results left the researchers baffled.   Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.”   Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015.  Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide.  Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous. 

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