Author Archives

John Irvine

Building Better Metrics: Focus on Patient Empowerment

Sep 26, 2016• 3

By NIRAN AL-AGBA, MD

flying cadeucii Growing up during the 1970’s and 80’s, the “Little House on the Prairie” television series was an iconic part of my childhood. Doc Baker was the physician and veterinarian for all of Walnut Grove, in spite of limited resources. Medical lessons were everywhere in the beloved television series: Mary experiencing onset of blindness (most recently attributed to viral meningoencephalitis, likely from Measles), the death of Laura’s infant son by unknown cause, and Rose’s survival after smallpox infection.

When patients ask me how to start solid foods, how to get a baby to sleep through the night, or how to treat minor injuries or burns, I frequently wonder if they would have asked the town doctor these same questions one hundred years ago.

Probably not, because they would know to watch their baby for hunger cues, let infants cry it out at night, or slap some egg white, aloe, or honey on their wounds or burns to prevent infection back then. Empowering patients to treat themselves where appropriate has tremendous value to cut down on cost and consumption of precious resources. It was also how medicine was practiced more than a century ago.

The Rise and Decline
of the Dartmouth Atlas

Sep 25, 2016• 5

By KIP SULLIVAN

flying cadeucii In my first comment in this series (an open letter to President Obama), I criticized Obama for stating in an article in the Journal of the American Medical Association that the Affordable Care Act is deflationary. I promised him I would post more essays showing how badly he had been misled by three experts who influenced him: Elliott Fisher and his colleagues at the Dartmouth Institute, Atul Gawande, and Peter Orszag.

My second post presented evidence that the research by Fisher et al. on regional variation in Medicare spending has been enormously influential with US policymakers for the last three decades.

In this comment, I demonstrate the gross inaccuracy of the Dartmouth group’s research.

Let me state at the outset: Even if every paper Fisher et al. wrote about regional variation in Medicare spending were true, none of them constituted evidence for the “accountable care organization.” In other words, even if we accept the Dartmouth group’s claim that regional and hospital variation is due primarily to overuse, we would still have no reason to accept the group’s claim that ACOs are the solution to all that overuse.Continue reading…

Practicing Physicians and Healthcare Reform: Population Health vs. Compensation Wealth

Sep 25, 2016• 1

By NATHAN KAUFMAN

In her August 14^th 2016 interview with the LA Times regarding the ACA and value-based reimbursement, HHS Secretary Sylvia Burwell stated, …”and medical providers want this.¹” After reading this article, I wondered for a moment if I am working in the same healthcare system as the Secretary. Having spent a significant part of my 36-year career negotiating financial transactions with and/or on behalf of practicing physicians, I can unequivocally state that, unlike healthcare thought -leaders and policy wonks, a scant few practicing physicians are on board with population health management, value-based care and the “triple aim.”

It is essential to significantly improve the value of healthcare and it will require a lot of work by all. Given the disconnect between the policy makers/‘thought- leaders’ and the nation’s practicing physicians, I am pretty sure we are not going to get very far. Most practicing physicians consider the current movement to value based care/population health to be ineffective, expensive, bureaucratic interference with the practice of medicine.

For Healthcare Cybersecurity the Whole is Weaker Than the Sum of the Parts

Sep 23, 2016• 3

By JESSE WALKER and ROSS KOPPEL

flying cadeucii Before addressing the special attractions and vulnerabilities of healthcare data and software, a little background on cybersecurity of complex systems may be helpful: The single most important lesson from our experiences with conventional networked systems is that all of them can be hacked, and all will eventually be hacked. There’s a simple equation for hackers: their investments are related to the value of the data. Alas, because electronic health records (EHRs) have a relatively high value to criminals, we should expect hackers to make significant efforts to penetrate EHRs. (More on this later.) Our experience also teaches us that erecting protections to mitigate hacking is never by itself an adequate defense. Instead, it is always necessary for health IT leaders to make significant efforts monitoring the EHR system for unanticipated behavior. Equally critical, it’s always necessary to plan how to respond to detected attacks.

Two mistakes: One of the biggest mistakes organizations make is failing to understand the threat; organizations typically are uninformed about the sophistication and resources of attackers, on one hand, and so underestimate their opponents, while on the other, they assume their systems are much less vulnerable than they actually are.

A Fail For Activity Trackers: The I Told You So’s vs Need More Datas

Sep 22, 2016• 3

By DAVID SHAYWITZ, MD

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Perhaps the normally measured physician-economist Aaron Carroll best captured the reaction and sentiments of the healthcare community in response to a recent JAMA article demonstrating that subjects in a weight reduction study using activity trackers lost significantly less weight than those in the control group:

“I TOLD YOU SO!!!!!!” (Emphasis in original.)

These results were cheered for several key reasons.

First, many in healthcare are irritated by the idea of simplistic technical fixes for complex medical (and social) (and cultural) (and economic) problems–like obesity.

Second, as Carroll has pointed out, exercise is healthy for many reasons, but weight loss is probably not one of them; changing your diet seems to matter a lot more.

However, it’s important to critically evaluate research even (especially) when it seems to produce an ego-syntonic conclusion–a conclusion with which we so strongly agree.

My initial reaction to the result was that perhaps it reflects an example of the concept of “moral licensing” that Malcolm Gladwell discusses so thoughtfully on his Revisionist History podcast–i.e., when you deliberately act morally in one context, you may be more likely to act less morally in another context, having already demonstrated to yourself your moral bona fides.

So, Do Transparency Tools Actually Work?

Sep 21, 2016• 1

By DEVON HERRICK

flying cadeucii A new report by economist Jon Gabel and his colleagues at NORC, a research center affiliated with the University of Chicago, looked at the use of transparency tools in an employer health plan. The analysis found the use of price transparency tools to be spotty. For instance, 75 percent of households either did not log into the transparency tool or did so only one time in the 18-month period of study. Fifteen percent did so twice; but only 1 percent logged in 6 times or more. The authors concluded:

It could very well be that we are asking too much of a single tool, no matter how well-designed. Consumer information for other goods and services on price and quality are seldom dependent upon information gained mainly, if not solely, through a digital tool. Rather, information on relative value is spread far and wide through advertising and other kinds of promotion using conventional, digital, and social media communication channels.

An earlier Harvard study on transparency tools, published in JAMA, found patients do not tend to use the tools to comparison shop for lower prices (in fact, spending rose slightly). An NBER study concluded that when transparency tools do lower spending, it is because consumers used to tools to identify prices and use the information to decide whether they can afford the service and skip it if they cannot.

The transparency tool in the current study also emailed “Ways to Save” suggestions on how consumers could reduce medical spending. The authors made an important observation:

It is also possible that the message on the “Ways to Save” e-mail turned off many households. While the emails did highlight opportunities to save a specific amount of money, a vast majority of the savings were for the employer and a much smaller amount of savings applied to the employee. It is possible that many employees viewed the transparency initiative as simply a means for the employer to save money.

Statin Wars: Less-is-More versus Unlimited Medicine

Sep 20, 2016• 8

By SAURABH JHA, MD

flying cadeucii It is the beauty of evidence-based medicine (EBM) that a scientist can at once be a Pope and a Galileo. His transmutation is as effortless as it is discretionary. If you think you’ve met Galileo – a rebel, a free thinker, a rocker of the establishment – the following week he is a Pope, castigating detractors, censoring critics, and celebrating uniformity. He changes by a roll of the dice. His change is decided by a quirk in hypothesis-testing known as statistical significance. If the p value is 0.051 he is Galileo, if the p value is 0.049 he becomes the cardinal. He is one day a raging skeptic and another day a true believer.

The latest fight between orthodoxy and free inquiry is about the benefits and harms of statins for primary prevention. A review, and an editorial, in the Lancet said the benefits of statins are real, the harms are exaggerated, and skepticism of benefits of statins should be censored because doubt can harm the public who may not take their statins and thus die prematurely. Stated differently, skepticism kills. The lead author of the review once asked the BMJ to retract a study which he felt overplayed the harms and denied the benefits of statins. The editor compared the fear about statins to fear about vaccination. Statin skeptics, like vaccine deniers, are now medicine’s truthers.

The Rest of the Story About the Economic Good News

Sep 19, 2016• 1

By PAUL KECKLEY

Legendary radio commentator Paul Harvey ended his daily report with a final story introduced by the tease “Now for the rest of the story.”

Last Tuesday, the U.S. Census Bureau announced that median household income increased 5.2% in 2015 to $56,516—the first increase in inflation adjusted income since the start of the downturn in 2007.

The Bureau also noted that the U.S. poverty rate decreased to 13.5% in 2015, down from 14.8% in 2014 and those lacking health insurance coverage shrank to 9.1% from a high of almost 16% in 2007. According to the Center for Budget and Policy Priorities, that’s the first time all three have improved in 20 years which it attributes to a lower unemployment rate (5.3% vs. 6.2% in 2014) representing an increase of 3.3 million in the workforce. That’s the story, but here’s the rest of the story.

Closer to a crisis

Sep 17, 2016• 4

By FRED TROTTER

Fred_Trotter How close to we need to get to cybersecurity crisis in healthcare before we, as an industry take deliberative action?
Should we approach cybersecurity in healthcare differently? What approaches will work best? What commonly repeated advice about cybersecurity is actually wrong in healthcare settings? What ideas that would be effective in healthcare cybersecurity are being ignored? What is being missed from discussions about healthcare cybersecurity? What are we too concerned about? What threats do not get enough attention?

These might sound like rhetorical questions, designed to engage the reader before the author knowingly reveals the “answer”. Sadly, these questions are no rhetorical device. No one has definitive answers, and we all desperately need them.

I sit on the Health Care Industry Cybersecurity Task Force and we are currently taking comments on these issues on this blog post. I cannot to presume speak for the Task Force as a whole, and the comments below represent only my personal perspective on the issues involved. Right now the only thing that the Task Force as a whole is comfortable saying is “we are asking for advice”, which is the purpose of the blog post. If you have a reaction to the personal opinions here, please comment on the blog post so that the whole Task Force can hear what you have to say.

Generally, there are two types of issues that we would like advice on:

“What are the best practices and correct strategies to defend healthcare technology from cybersecurity attacks?” and “What is the best way for US government agencies to coordinate with the healthcare industry to respond quickly and effectively to cybersecurity threats?”