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If We Want Lower Health Care Spending, We Are Going to Have to Pay for It

May 26, 2014• 13

By David Dranove & Craig Garthwaite

Ultimately, spending less on health care is a relatively easy task: We either need to consume fewer services, or spend less on the services that we consume. But much like we teach our Kellogg students about maximizing profits, the devil is in the details.

It’s certainly tempting to ask the government to swoop in on a white stallion and solve the all our problems by fiat. For example, we could have the government simply exploit its monopsony power and set prices, but an artificially low price will lead to an inefficiently low quantity of services and future innovation (stay tuned, we will have more to say about this next week).

Similarly, we could explicitly ration quantities (as opposed to implicitly doing it through a large uninsured population). But how could we hope to determine the right level of care? Ultimately, if we ask the government to unilaterally fix this problem, instead of a white stallion we could behold a pale horse and all that it entails.

The good part, perhaps the best part, about the Affordable Care Act is that it attempts to address this problem using market forces. The question is whether we are ready for what these market forces will entail.

We will focus today on the role of market forces in the insurance market to control prices in the newly established ACA exchanges.

This month the Obama administration announced that it would allow insurers to use “reference pricing” for insurance programs in the exchanges. Under a reference pricing system, insurers set the maximum price they will pay for a specific set of services and if patients go to a facility that costs more than that amount they are required to pay the difference.

If Marketing Is so Dangerous, Should Medical Schools Be Doing so Much of It?

May 25, 2014• 5

By Richard Gunderman, MD

Beginning about 5 years ago, many US medical schools introduced severe restrictions on marketing activities by pharmaceutical companies and medical device manufacturers.

These measures often prohibited representatives of such firms from entering patient care areas and even medical school facilities, with the exception of tightly controlled training activities, and then by appointment only. In some cases, medical schools have issued outright bans against industry support of educational activities.

What is the rationale behind such actions? It boils down to a concern that industry funding may inappropriately influence both medical education and patient care. For example, a physician visited by an industry representative might be more likely to prescribe one of the firm’s drugs. In announcing a ban on such activities, one school likened the industry to Don Juan, worrying that physicians might prescribe drugs because they were “seduced by industry,” and not because “it’s best for the patient.”

There is evidence that even physicians who believe their decision making is not biased by marketing are in fact affected by it. Moreover, a good deal of such marketing is not exactly purely scientific. A perusal of medical journals reveals a plethora of full-page ads featuring slogans such as:

“Simplicity is clear information at your fingertips,” and highlighting images such as a physician walking down a hallway with a tiger, describing the featured drug as a “powerful partner.”

Such marketing is not inexpensive. Placing a full-page ad in a medical journal typically costs around $4,000. On the other hand, as an air traveler I have come across a number of slick full-page airline magazines ads touting medical schools and their affiliated hospitals.

These cost on average $24,000.

Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too ..

May 23, 2014• 19

By Elaine Khoong

“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.

We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.

What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.

Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.

Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.

I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?

A New Era in Value-Driven Pharmaceuticals

May 22, 2014• 3

By Leonard Kish & Cyndy Nayer

At the end of March the Amercian College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint statement saying they “will begin to include value assessments when developing guidelines and performance measures (for pharmaceuticals), in recognition of accelerating health care costs and the need for care to be of value to patients.”

You may have heard of value-based medicine, but are we entering a new era of value-based medications or value-driven pharma?

Price transparency is great, but it has be combined with efficacy to get to value (price for the amount of benefit). Medical groups are catching on to how important value assessments are, because if patients can’t afford their medication, they won’t take their medication, and that obviously can turn into poor outcomes.

Twenty-seven percent of American patients didn’t fill a prescription last year according to a Kaiser Family Foundation Survey. This trend seems likely to continue as we move toward higher-deductible plans, where those with insurance can have great difficulty affording medications.

Included in the ACC/AMA statement was a quote from Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine.

“There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed…These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources.”

Spreading risk and payment to different members of the health care value chain is beginning to make it apparent to more people and organizations that resources are finite. Patients and their physicians are starting to ask which treatments are worth the cost and have best likelihood of adherence.

An outgrowth of the move toward digital health and accountable care is that we’re entering every patient into a potential personal clinical trial with their data followed as a longitudinal study, and we can look much more closely at efficacy and adherence and reasons why it happens and why it doesn’t.

It won’t be long before we start to see comparative effectiveness across a variety of treatments and across a variety of populations. When we can connect outcomes data, interventions and costs all in the same picture we begin to see where the value (price against results) is and where it isn’t.

Because Cancer.

May 21, 2014

By “Knot Telling”

Do not tell me how to feel!

For those who may not read through to the end, here is the take home: you do not get to tell me how to feel or what my attitude should be, no matter who you are.

Sure, it’s more comfortable for me and the people around me when I’m have a positive attitude, but that does not mean that I have to live “all bliss all the time” like some insane American cable television station. Being positive does not mean pretending that nothing is wrong because… cancer, people!

A young woman who, I think, just turned twenty-two posted this on her Facebook page: “That’s the thing about pain. It demands to be felt.” She knows what she is talking about, by the way.

It does no good to pretend that emotional pain does not exist. It does no good to pretend that it’s not there. The only way I’ve ever found to get through pain is to recognize it, sit with it, walk through it to the other side. Sometimes that process leaks out into the environment and then I don’t smile prettily at everyone around me. Sometimes I’m snotty and bitchy and generally not one of Jesus’ little sunbeams. Sorry about that, but… cancer, people!

Here’s another news flash. A positive, determined attitude will not cure cancer, no matter what the popular media tell you. The following quotations are from the American Cancer Society:

In 2010, the largest and best-designed scientific study to date was published. It looked at nearly 60,000 people, who were followed over time for a minimum of 30 years. This careful study controlled for smoking, alcohol use, and other known cancer risk factors. The study showed no link between personality and overall cancer risk. There was also no link between personality traits and cancer survival.

[…]

Continue reading…

Scope of Practice: Playing at the Top of My License?

May 20, 2014• 25

By Karen S. Sibert, MD

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

Harvard MOOC: Patient Safety and Quality with Ashish Jha

May 15, 2014• 22

By Ashish Jha, MD

Last year, about 43 million people around the globe were injured from the hospital care that was intended to help them; as a result, many died and millions suffered long-term disability. These seem like dramatic numbers – could they possibly be true?

If anything, they are almost surely an underestimate. These findings come from a paper we published last year funded and done in collaboration with the World Health Organization. We focused on a select group of “adverse events” and used conservative assumptions to model not only how often they occur, but also with what consequence to patients around the world.

Our WHO-funded study doesn’t stand alone; others have estimated that harm from unsafe medical care is far greater than previously thought. A paper published last year in the Journal of Patient Safety estimated that medical errors might be the third leading cause of deaths among Americans, after heart disease and cancer.

While I find that number hard to believe, what is undoubtedly true is this: adverse events – injuries that happen due to medical care – are a major cause of morbidity and mortality, and these problems are global. In every country where people have looked (U.S., Canada, Australia, England, nations of the Middle East, Latin America, etc.), the story is the same.

Patient safety is a big problem – a major source of suffering, disability, and death for the world’s population.The problem of inadequate health care, the global nature of this challenging problem, and the common set of causes that underlie it, motivated us to put together PH555X.

It’s a HarvardX online MOOC (Massive Open Online Course) with a simple focus: health care quality and safety with a global perspective.

Introducing PH555X: Improving Global Health: Focusing on Quality and Safety

May 15, 2014• 6

[youtube]http://www.youtube.com/watch?v=00wx9NaGA8g[/youtube]

Another Step toward Open Health Education

May 14, 2014• 17

By Gaglani, Haynes & Painter

Earlier this month Shiv and Ryan published a piece in the Annals of Internal Medicine, entitled What Can Medical Education Learn from Facebook and Netflix? We chose the title because, as medical students, we realized the tools our classmates are using to socialize and watch TV use more sophisticated algorithms than the tools we use to learn medicine.

What if the same mechanisms that Facebook and Netflix use—such as machine learning-based recommender systems, crowdsourcing, and intuitive interfaces—could transform how we educate our health care professionals?

For example, just as Amazon recommends products based on other items that customers have bought, we believe that supplementary resources such as questions, videos, images, mnemonics, references, and even real-life patient cases could be automatically recommended based on what students and professionals are learning in the classroom or seeing in the clinic.

That is one of the premises behind Osmosis, the flagship educational platform of Knowledge Diffusion, Shiv’s and Ryan’s startup. Osmosis uses data analytics and machine learning to deliver the best medical content to those trying to learn it, as efficiently as possible for the learner.

Since its launch in August, Osmosis has delivered over two million questions to more than 10,000 medical students around the world using a novel push notification system that syncs to student curricular schedules.

Osmosis is aggregating medical school curricula and extracurricular resources as well as generating a tremendous amount of data on student performance. The program uses adaptive algorithms and an intuitive interface to provide the best, most useful customized content to those trying to learn.

Cheeseburger Please, and Make It a Double

May 14, 2014• 36

By Vik Khanna

Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.

Our conversation about sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.

A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.

The authors correlate cancer mortality with age and protein intake, but they never bother to correlate it with body mass index or waist circumference, the latter of which is an increasingly important measure of body composition. Average waist circumference of the mostly older study subjects was just barely below risk thresholds, meaning that they were fat. Abdominal adiposity induces a damaging pro-inflammatory metabolic state than abets cancer development. Cancer is predominantly a disease of aging with incidence and death rates after age 50 that are 13x greater than before.