Author Archives

Matthew Holt

If HIT Plan A Doesn’t Work, What’s Plan B?

Jun 28, 2010• 42

By VINCE KURAITIS, JD, & DAVID KIBBE, MD

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue. He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

Defending Plan A to your dying breath?
Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.Continue reading…

Are Doctors Really Boycotting Medicare?

Jun 28, 2010• 25

By NAOMI FREUNDLICH

As Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn’t participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; “If the 21 percent cut goes into effect, we’re going to have a very severe problem in the state of Arizona.”

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

First off, all this is happening against the backdrop of a major political fight in Congress over how much the government should invest in economic recovery. On Friday, the Senate passed a “doc fix” that would postpone the 21% cut in Medicare payments for another six months and provides a 2% increase in reimbursement instead. Unfortunately for doctors—and the seniors they count as patients—Nancy Pelosi has signaled that she may not be willing to settle for such a short-term solution. According to Politico, Pelosi was “caught off guard last week when Reid suddenly opted to pull the Medicare issue out of a jobs and economic relief bill on which the two leaders have been working for months.” For more background on the long history of the “sustainable growth rate” formula that mandates the Medicare cuts (enacted in 1997 by a Republican administration) and the unlikelihood of it ever being instituted long-term, see Maggie’s recent post here.Continue reading…

A Tale of Two Diseases: Repairing Comparative Effectiveness Research

Jun 28, 2010• 4

By DAVID E. WILLIAMS

Writing in the New England Journal of Medicine (Identifying and Eliminating the Roadblocks to Comparative-Effectiveness Research) three authors share their experience in running a head-to-head trial of Avastin (bevacizumab) versus Lucentis (ranibizumab) for wet age-related macular degeneration (AMD). They describe the barriers they faced and suggest that they will need to be removed for comparative effectiveness research –as envisioned under ARRA– to succeed. They make good points and may well be correct in their policy recommendations.

However the case of Avastin and Lucentis is unusual. The products are made by the same manufacturer and are essentially identical. Avastin and Lucentis are marketed separately by Genentech mainly to allow the company to capture a return on investment from its R&D. The issue is that a regular dose of Avastin (e.g., for lung cancer) can be divided up into many doses for the eye. Since the products are sold by volume it turns out that Avastin is cheap when used for wet AMD, even though it’s pricey when used for cancer. As I’ve suggested previously, Genentech should be able to charge Lucentis prices for Avastin when it’s used in the eye. So there are quite a lot of people –starting with the manufacturer itself– who didn’t really want this study to go forward. That’s less likely to be the case with other studies.Continue reading…

Why England is out of the World Cup

Jun 27, 2010• 9

By Matthew Holt

I don’t often write about Footy any more on THCB, but England is out of the World Cup today, stuffed 4–1 by Germany. So I thought I’d give my opinion, and for the moment I’m dropping my dual nationality and writing as an Englishman!

Why did we lose? Realistically England doesn’t have enough good players because England’s population is too small (50m vs 80m Germans) and—as pointed out in Soccernomics—the working class ethos against middle & upper class kids limits our potential pool of players even more—as England’s working class population is falling relatively as more kids go to college. In general England could improve our football team by changing its economy to match the slums of Argentina’s or Brazil’s but I wouldn’t take that as a fair trade. After all, the US dominates international sport (except its fifth most important sport soccer) because it has a huge urban underclass with a great feeder system (that’s colleges!) to getting them into basketball/American Football/Track etc. And it may well be that with more and more kids from the big urban centers getting into soccer, America can only improve. It’s a decent prediction that the US will win the World Cup in the next 50 years or so. Unlikely that England ever will again.

RFID Tags for Nurses. Then Everybody?

Jun 27, 2010• 2

By FRANK J. PASQUALE

The recent City of Ontario v. Quon decision has had a mixed reception among privacy advocates. Though many are disappointed that employees’ privacy rights have once again been narrowed, some have discerned helpful dicta in the case. However, I worry that, whatever the drift of thought among swing justices, economic imperatives and cultural shifts will mean a lot less privacy in the workplace of the future. Health care in particular offers a few interesting bellwethers.

As an opinion piece by Theresa Brown explains, maintaining proper staffing levels in hospitals is becoming increasingly difficult. Surveillance systems are offering one way to address the problem; work can be performed more intensively and efficiently as it is recorded and studied. But such monitoring has many troubling implications, according to Torin Monahan (in his excellent book, Surveillance in a Time of Insecurity):

The tracking of people [via Radio Frequency Identification Tags] represents a . . . mechanism of surveillance and social control in hospital settings. This includes the tagging of patients and hospital staff. . . . When administrators demand the tagging of nurses themselves, the level of surveillance can become oppressive. . . . [because nurses face] labor intensification, job insecurity, undesired scrutiny, and privacy loss. . . . To date, such efforts at top-down micromanagement of staff by means of RFID have met with resistance. . . . One desired feature for nurses and others is an ‘off’ switch on each RFID badge so that they can take breaks without subjecting themselves to remote tracking. (122)

Like the “nannycam” employed by many a wary parent, the nurse-cam may be seen as a way to protect the vulnerable. It may also increase the accuracy of evidence in malpractice cases. On the other hand, inserting a tireless electronic eye to monitor what is already an extremely stressful job may create many unintended consequences, or deter people from going into nursing altogether. Even advocates of pervasive surveillance recognize these difficulties.Continue reading…

Do Physicians Have a Right to Privacy?

Jun 25, 2010• 20

By MARGALIT GUR-ARIE

As we move to Electronic Health Records (EHR), the debates over security and privacy are becoming more frequent and more poignant. We of course have HIPAA laws on the books and ONC has a Tiger team assembled to recommend privacy and security policies to Secretary Sebelius. CIOs and entire IT departments are all focused on protecting the privacy of patients and their Personal Health Information (PHI). This is, of course, as it should be, but how about privacy of those taking care of patients? Do physicians have a right to privacy too?

As EHRs become more prevalent and interconnected, increasing amounts of clinical and administrative data will be flowing out of doctors’ offices and into the great beyond. Most of this data is indeed patient data, but some of it could be combined, sliced and diced to derive pretty extensive information about doctors. For example, and in no particular order:

Prescribing patterns – Prescription data has been collected and sold to pharmaceutical companies for decades. EHRs will make this much easier to accomplish and the data will become richer and more granular, since it will contain the exact nature of the visit where a particular drug was prescribed or discontinued, including physician notes on the subject. Of course, such information finding its way to public websites would present a novel difficulty if, say, we can look up Dr. X and see that she wrote 30 prescriptions for contraceptives last month, half of which were for girls under 16 years of age.Continue reading…

The Promise of Medicine

Jun 25, 2010• 14

By EDWARD D. MILLER, MD

Dr. Miller is the Dean and CEO of The Johns Hopkins University Medical School. These remarks were made at the National Press Club, June 21, 2010.

I. The Promise of Medicine

Let me start with a short story: It was the summer of 1971. I had just finished my training in anesthesia at the Peter Bent Brigham Hospital and was about to embark on a two-year fellowship in physiology at Harvard. I was asked if I wanted to be “the” anesthesiologist for the month of August on Martha’s Vineyard. It was to be part vacation and part work, and I needed the money.

Shortly after arriving, a young woman (who now runs a well-known tavern in that community), needed a surgical procedure. She had no insurance but was able to pay the medical bills out of pocket. She, however, could not afford the normal three-day stay in the hospital. She pleaded with me to have the minimal amount of medicine so she could be discharged the same day. To this day, I vividly recall helping her out to her car so that she could recover at home. You see, at the time, there was really no such thing as outpatient surgery.

Thanks to a revolution in anesthetics, outpatient surgery is a very common norm today. In fact, at Johns Hopkins Medicine facilities, we performed twenty-four hundred such procedures just last month.Continue reading…

Radio Stardom and the World Cup

Jun 24, 2010

By Matthew Holt

I (and a few THCB friends like Brian Klepper, Maggie Mahar, Michael Millenson & Barbara Ficarra) have been doing quick spots on KOMO a talk radio station in Seattle. We’re on every Tuesday & Friday at about 10.25 EST. Usually I forget to record it but today I captured my 60 seconds of joc(k)ular wisdom on the topic of whether late goals in the World Cup are bad for your health?

Here’s the interview…(only 90 seconds!)

Soccer bad for your health?

Private Equity in Health Care

Jun 24, 2010

By FRANK PASQUALE

As lawmakers squabble
over the “carried interest” tax rate, it’s nice to find a big picture
overview of some of the economic activity they’re discussing. I recently
read Josh Kosman’s book The
Buyout of America: How Private Equity Will Cause the Next Great Credit
Crisis, and I highly recommend it to our readers. Kosman painstakingly
describes the byzantine financial maneuvers behind marquee private
equity firms which bought “more than three thousand American companies
from 2000-2008.” He describes in detail how they resist transparency
(164) and “hurt their businesses competitively, limit their growth, cut
jobs without reinvesting the savings, and generate mediocre returns”
(195). The recipe for high earnings is simple: the firms “get large
fees up front and are largely divorced from their results if their
transactions fail” (195).

Like Kwak and Johnson’s account in 13 Bankers, Kosman offers
a political economy account of private equity’s favored treatment by
government. As he notes,

[F]our of the past eight Treasury Secretaries joined the
PE industry . . . . and they have significant influence in Washington.
President Bill Clinton, and both President Bushes, have also advised PE
firms or worked for their companies. . . . KKR retained former
Democratic House majority leader Richard Gephardt as a lobbyist and
hired former RNC chairman Kenneth
Mehlman as head of global public affairs. (196)

Having analyzed a wide array of buyouts, Kosman concludes that “PE
firms manage their businesses to satisfy short-term greed, not for
long-term survival” (51). This is a particularly dangerous attitude in
health care, an industry too long dominated by short-run thinking.

The Dartmouth Team Responds (Again)

Jun 23, 2010• 16

By JONATHAN SKINNER, PhD

Reed Abelson and Gardiner Harris, the authors of the June 4th New York Times article critical of the Dartmouth Atlas and research, have acknowledged Elliott Fisher and my concerns and clarified the record in their posting on the New York Times webpage. They originally claimed that we failed to price adjust any of the Atlas measures. They now acknowledge that we do, but they’re hard to find on the Atlas website, a point we concede. They originally claimed that quality measures were not available on the Atlas website. They now acknowledge that quality measures are on the website, but they don’t like them. We agree quality measures can be better – the type of research we do is always open to improvement — and Dr. Fisher has recently co-chaired an NQF committee with precisely this goal. (See our more detailed response.)

But the primary purpose of this posting is to respond to the attack by Mr. Harris on the professional ethics of the Dartmouth researchers. The key issue seems to be whether the research in two landmark 2003 Annals of Internal Medicine articles (here and here) were misrepresented by the Dartmouth researchers. In his posting Mr. Harris asserts:

In an aside, when was the last time you saw researchers so profoundly mischaracterize their own work? How is it possible that they could claim their annals pieces concluded something when they didn’t? I can’t remember ever seeing that happen.

We are disappointed by this accusation. We can understand Mr. Harris’s frustrations in understanding the research, as it is often nuanced and tricky to follow. This lack of understanding is illustrated by their recent New York Times posting, where they state:

In statistical terms, [the Dartmouth researchers’] claim is referred to as a negative correlation between spending and health outcomes, which means that when spending goes up, the health of patients goes down.

They have confused the idea of a correlation (high spending hospitals on average do slightly worse on quality and outcomes) with causation (if a hospital spends more money, outcomes for those patients will get worse).

The more fundamental point, however, is their claim that we misrepresenting the two 2003 Annals of Internal Medicine studies written by Dr. Fisher and others. Ms. Abelson and Mr. Harris state that

The Dartmouth work has long been cited as proving that regions and hospitals that spend less on health care provide better care than regions and hospitals that spend more…. As the article noted, [Dr. Fisher] asked in Congressional testimony last year, “Why are access and quality worse in high-spending regions?”