Author Archives

John Irvine

Hacking Doctors

Apr 11, 2016• 1

By MARGALIT GUR-ARIE

flying cadeucii For decades and decades we have been counting the number of doctors in America. For decades and decades we have been coming up short compared to other developed nations, and some less developed ones as well. A poorly educated person may be tempted to suggest that we should “make” more doctors. After all, there is hardly a shortage of young people willing and able to undergo the rigors of a medical education. But luckily we are not poorly educated, so we devised much smarter solutions.

If people can’t get a doctor appointment, it must be the doctor’s fault. Hence, we put our foot down and mandated that doctors see people the same day they want to be seen, or shortly thereafter. It sounds great and it worked perfectly for the Veterans Administration (VA), so it should scale terrifically to everybody else.Taking a page from the highly respected Samuel Hahnemann, we decreed that physically “seeing” an actual doctor is not only completely unnecessary, but it may very well be detrimental to the healing process. A doctor effect is created by simply having an MD somewhere in the building, and as technology continues to improve, a virtual doctor presence should do the trick. Some have argued that Mr. Hahnemann’s homeopathic fantasy is no better than a placebo, but we have plenty of research showing that placebos are indeed effective.Continue reading…

What to do About Health Care Data Sharing

Apr 8, 2016• 2

By DAN HOUSMAN

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In my last blog I riffed on prospect theory and how it applies to health care data sharing. In essence, prospect theory suggests two categories:

1. People are extremely unwilling to accept risk when the consequences are unknown (patients avoid sharing data if they don’t know how it will benefit or harm them)

2. People are more willing to accept the risk when the reward is achievable, and the alternative is very harmful (patients with severe illnesses would readily share data when there is a possibility it could save their life or eliminate significant suffering)

Scenario 1, risk adversion, is more common across all constituents including providers, healthy patients and families, political leaders and philanthropists. Generally, the benefits of sharing health care data are foggy and unclear, while the alternatives to keeping the data private are not life threatening.

Trump’s Healthcare Plan: Right Diagnosis, Wrong Prescription

Apr 8, 2016• 6

By SALLY C. PIPES

Screen Shot 2016-04-08 at 9.37.58 AM Donald Trump recently released a healthcare reform plan. If only he had spent as much time crafting it as he does his hair.

The GOP frontrunner is right that Obamacare has failed to fix what ails America’s healthcare system. As Trump put it, the Affordable Care Act has “tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices.” He famously said that he wants to “repeal and replace with something terrific.”

But “terrific” his plan is not.

Take, for instance, his proposal to legalize the importation of “safe and dependable [prescription] drugs from overseas.”

Importing cheaper drugs from other countries may seem like a great way to reduce the cost of medicine for Americans. But there are important reasons why it’s currently prohibited.

What Might We Expect in the MACRA Proposed Rule?

Apr 6, 2016• 1

By DAVID INTROCASO

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Nearly a year ago President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. MACRA, among other things, repeals the 1997 Balanced Budget Act’s Sustainable Growth Rate (SGR) formula for calculating annual updates to Medicare Part B physician and other eligible professionals’ payment rates.1 The bill received overwhelming support in both the House and Senate, only 45 out of 529 total votes cast opposed the bill despite the fact the legislation is estimated to add $141 billion to the federal deficit by 2025.2 Support for the legislation can, in part, be attributed to the Congress having grown tired of rescinding SGR mandated payment cuts or passing nearly 20 “doc fix” “patches,” over 18 years. Presently, Medicare physicians are awaiting CMS’s proposed rule that will define how the agency intends to implement the six sections of MACRA Title I, or how the agency will annually update physician performance beginning in 2019 based on the use of the law’s Merit-Based Incentive Payment System (MIPS) and its Alternative Payment Models (APMs) pathway. The proposed rule, expected to be published in the next few weeks, is highly anticipated because the rewards and penalties under either MIPS and APMs can be significant.

Meaningful Use: RIP

Apr 5, 2016• 10

By RICHARD GUNDERMAN, MD

Richard Gunderman good A decade ago, electronic health records were aggressively promoted for a number of reasons. Proponents claimed that they would facilitate the sharing of health information, reduce error rates in healthcare, increase healthcare efficiency, and lower costs. Enthusiasts included the technology companies, consultants, and IT specialists who stood to reap substantial financial rewards from a system-wide switch to electronic records.

Even some health professionals shared in the enthusiasm. Compared to the three ring-binders that once held the medical records of many hospitalized patients, electronic records would reduce errors attributable to poor penmanship, improve the speed with which health professionals could access information, and serve as searchable information repositories, enabling new breakthroughs through the mining of “big data.”

To promote the transition to electronic records, the federal government launched what it called its “Meaningful Use” program, a system of financial rewards and penalties intended to ensure that patients would benefit. Naturally, this raised an important question: if digitizing health records was such a good idea, why did the federal government need to impose penalties for health professionals who failed to adopt them? Perhaps electronic health records were not so self-evidently beneficial as proponents suggested.

The Patient-Centered Doctor

Apr 4, 2016• 10

By ROB LAMBERTS, MD

flying cadeucii I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don’t listen to what you have to say. What do you do when your patients don’t take the medications you prescribe?”

I totally wrecked his point, which made me glad because I didn’t agree with it anyhow.

Since I am in the midst of a series of posts on patient-centeredness in healthcare, I need to take a quick (1,200’ish word) detour to an important related question: what happens when the patient doesn’t cooperate? What does patient-centered care look like with non-compliant patients?

If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven’t taken prescribed medications: they look guilty — like they are expecting to be scolded. I guess scolding is what they’ve had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It’s as if the patient is not taking their medication with the express intent of irritating their doctor.

But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient’s job is to “obey” what they’ve been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS healthcare, aren’t we?

Research Bites Dog

Apr 3, 2016• 8

By JOSEPH KVEDAR, MD

Screen Shot 2016-04-03 at 10.42.56 AM We live in a headline/hyperlinked world. A couple of years back, I learned through happenstance that my most popular blog posts all had catchy titles. I’m pretty confident that people who read this blog do more than scan the titles, but there is so much information coming at us these days, it’s often difficult to get much beyond the headline. Another phenomenon of information overload is that we naturally apply heuristics or short cuts in our thinking to avoid dealing with a high degree of complexity. Let’s face it: it’s work to think!

In this context, I thought it would be worth talking about two recent headlines that seem to be set backs for the inexorable forward march of connected health. These come in the form of peer reviewed studies, so our instinct is to pay close attention.

In fact, one comes from an undisputed leader in the field, Dr. Eric Topol. His group recently published a paper where they examined the utility of a series of medical/health tracking devices as tools for health improvement in a cohort of folks with chronic illness. In our parlance, they put a feedback loop into these patients’ lives. It’s hard to say for sure from the study description, but it sounds like the intervention was mostly about giving patients insights from their own data. I don’t see much in the paper about coaching, motivation, etc.

If it is true that the interactivity/coaching/motivation component was light, that may explain the lackluster results. We find that the feedback loops alone are relatively weak motivators. It is also possible that, because the sample included a mix of chronic illnesses, it would be harder to see a positive effect. One principle of clinical trial design is to try to minimize all variables between the comparison groups, except the intervention. Having a group with varying diseases makes it harder to say for sure that any effects (or lack of effects) were due to the intervention itself.

Dr. Topol is an experienced researcher and academician. When they designed the study, I am confident they had the right intentions in mind. My guess is they felt like they were studying the effect of mobile health and wearable technology on health (more on that at the end of the post). But you can see that, in retrospect, the likelihood of teasing out a positive effect was relatively low.

The Thing About the IoT

Apr 2, 2016

By BROOKINGS INSTITUTION

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In the coming years, the number of devices around the world connected to the Internet of Things (IoT) will grow rapidly. Sensors located in buildings, vehicles, appliances, and clothing will create enormous quantities of data for consumers, corporations, and governments to analyze. Maximizing the benefits of IoT will require thoughtful policies. Given that IoT policy cuts across many disciplines and levels of government, who should coordinate the development of new IoT platforms? How will we secure billions of connected devices from cyberattacks? Who will have access to the data created by these devices? Below, Brookings scholars contribute their individual perspectives on the policy challenges and opportunities associated with the Internet of Things.

The Internet of Things will be Everywhere

Humans are lovable creatures, but prone to inefficiency, ineffectiveness, and distraction. They like to do other things when they are driving such as listening to music, talking on the phone, texting, or checking email. Judging from the frequency of accidents though, many individuals believe they are more effective at multi-tasking than is actually the case.

The reality of these all too human traits is encouraging a movement from communication between computers to communication between machines. Driverless cars soon will appear on the highways in large numbers, and not just as a demonstration project. Remote monitoring devices will transmit vital signs to health providers, who then can let people know if their blood pressure has spiked or heart rhythm has shifted in a dangerous direction. Sensors in appliances will let individuals know when they are running low on milk, bread, or cereal. Thermostats will adjust their energy settings to the times when people actually are in the house, thereby saving substantial amounts of money while also protecting natural resources.

With the coming rise of a 5G network, the Internet of Things will unleash high-speed devices and a fully connected society. Advanced digital devices will enable a wide range of new applications from energy and transportation to home security and healthcare. They will help humans manage the annoyances of daily lives such as traffic jams, not being able to find parking places, or keeping track of physical fitness. The widespread adoption of smart appliances, smart energy grids, resource management tools, and health sensors will improve how people connect with one another and their electronic devices. But they also will raise serious security, privacy, and policy issues.

Torture the Data Until it Confesses

Mar 29, 2016• 9

By TOM EMERICK

flying cadeucii Did you ever hear the old joke where the boss says floggings will continue until morale improves? Torturing the data until results improve…or the data confesses…is not uncommon. Which is a pity.

In my career I’ve worked with companies with over 100k covered lives the claim costs of which could swing widely, from year to year, all because of a few extra transplants, big neonatal ICU cases, ventricular assist cases, etc.

Here are just a few of the huge single case claims I’ve observed in recent years:

$3.5M cancer case
$6M neonatal intensive care
$8M hemophilia case
$1.4M organ transplant
$1M ventricular assist device

This is not a complaint. After all this is what health insurance should be about, huge unbudgetable health events.

All plans have one organ transplant every 10k life years or so, most of which will cost about $1M over 6 years. A plan with 1k covered lives will have such an expense on the average of every 10 years. Of course the company may have none for 15 years and two in the 16th year. The same goes for $500k+ ventricular assist device surgeries.

Milestones or Millstones?

Mar 28, 2016• 1

By RICHARD GUNDERMAN, MD and DAREL HEITKAMP, MD

Gunderman Good intentions do not necessarily lead to good results. A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education. In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.

The goals behind the milestones initiative are laudable. Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes. They would foster self-directed learning and assessment and provide more helpful feedback. In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.

In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties. Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin. In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.