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Matthew Holt

Inspiration, spirit, connection, optimism–Health 2.0 Spring Fling

Apr 1, 2011

By Matthew Holt

It’s been crazy post Health 2.0 Spring Fling in San Diego, I tried do my wrap of highlights and feelings from this Health 2.0 before the plane touched down last week, but I never quite finished them. So with a little hindsight, here are some snippets of my experience. Now this was just one experience–Indu and I will write a more detailed statement about what’s next for Health 2.0 soon–but clearly the feeling at this intimate and deeply personal Health 2.0 was more about feelings, spirit and emotion than it was about technology.

Karen Herzog has been virtually at every Health 2.0 and she said right at the end that several companies are teaching wisdom and mindfulness and that we need to merge Wisdom 2.0 (yes that’s a conference too) with Health 2.0. My flip response was that I’d been working in the health care system twenty years and had yet to see any wisdom in it. Not true of course, but as Arnie Milstein pointed out, we have a system that continues to diverge the trend lines between health care cost growth and GDP growth. And at some point that “shark” jaws will bite us.

What really struck me and struck Karen too, was that one of the keys Arnie discovered for communities with high performing but lower cost health care systems (in the US) was that the patients there really felt that the medical team cared about them. He asked the audience how many people felt the same about their care providers–and from around 300 people fewer than five hands went up.

Flipping the whole conference around, we started with a period of intensely personal fireside chats. America’s pediatrician, Alan Greene, talking about the one moment that can change the obesity epidemic–the Whiteout movement’s pledge to make each baby’s first bite of food be real food, not white rice baby cereal. Kolya Kirienko told an incredible story of recording his own patient narrative saved his life several times, and how he is now (funded by Robert Wood Johnson Foundation’s Project Health Design) building a narrative-capturing system that will really help patients record observations of daily living.

Finally an amazing troika of JD Kleinke (read his new novel Catching Babies), Amy Romano (@midwifeamy) and Health 2.0’s own mum to be Indu Subaiya dived into the amazing microcosm of our health system that is obstetrics. JD told Amy: childbirth is the one place where the patient has a choice to really opt out. You can’t have your hip replaced at home in a tub by someone the medical profession abhors. But you can have your baby “caught” that way. And Indu discussed how she as an MD made the decision to move from the trad OBGYN to a midwife and birthing center.

And not a demo in sight.Continue reading…

Accountability? Heaven forbid!

Mar 31, 2011• 11

By PAUL LEVY

At a recent talk, Dartmouth’s Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won’t be accountable.

This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:

[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal – improving care while containing costs. They’re seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.

Here’s the one I like best:

The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. “Providers are better positioned than CMS to determine which of their patients would be appropriate candidates,” the federation wrote.

So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.

Oregon Death with Dignity Act vindicated

Mar 30, 2011• 2

To no one rational’s surprise, a study confirms that those few Oregon patients (400 over 10 years) who chose legal physician assisted suicide in case of terminal illness had a better quality of death than those who didn’t. Sadly because those attacking it aren’t rational, this won’t end the debate–but if you’re terminally ill you have better choices in Oregon (and Washington & Switzerland).

ACOs: Unicorn breeding rules emerging

Mar 30, 2011

Mark Smith, the President of the California Health Care Foundation, jokes that ACOs are like unicorns–mythical beasts that no one has yet seen. Well today Politico reports that–just like the Kennel club certifying a new breed of dog–CMS is about to come out with 1,000 pages of regulations telling us what an ACO is and what it can and can’t do. Should be fun.

A Normal Pregnancy Is a Retrospective Diagnosis

Mar 29, 2011• 63

By J.D. KLEINKE

The names in this article have been changed to protect the privacy of all individuals involved.

If every medical specialty has its homily for indoctrinating new members, “a normal pregnancy is a retrospective diagnosis” is the cynical soundbite for obstetrics. It is a patronizing and alarmist statement, meant to distance weary practitioners, terrify patients, silence objections from families, and establish the first defensive perimeter in the legal fortress that defines obstetrical practice in the US.

It is also the perfect, if inadvertent expression of how little obstetricians really know – and how limited the specialty is in its ability to test and expand that knowledge – thanks in part to the visceral fear inspired in patients by statements like “a normal pregnancy is a retrospective diagnosis.”

This homily serves as the opening taunt to one of the more quietly rebellious obstetrician/gynecologists (OB/GYNs) in my new book, Catching Babies. For reasons I’ll explain momentarily, the book began as an expose of the practice of high-risk obstetrics, but it quickly morphed into a novel, an ensemble drama about the brutalization of OB/GYNs during their residency training.

You’re Sick. I’m Not. Too Bad.

Mar 29, 2011• 41

By ELAINE SCHATTNER, MD

There’s a popular, partly true, sometimes useful and very dangerous notion that we can control our health. Maybe even fend off cancer.

I like the idea that we can make smart choices, eat sensible amounts of whole foods and not the wrong foods, exercise, not smoke, maintain balance (whatever that means in 2010) and in doing so, be responsible for our health. Check, plus.

It’s an attractive concept, really, that we can determine our medical circumstances by informed decisions and a vital lifestyle. It appeals to the well — that we’re OK, on the other side, doing something right.

There is order in the world. God exists. etc.

Very appealing. There’s utility in this outlook, besides. To the extent that we can influence our well-being and lessen the likelihood of some diseases, of course we can! and should adjust our lack-of-dieting, drinking, smoking, arms firing, boxing and whatever else damaging it is that we do to ourselves.

I’m all for people adjusting their behavior and knowing they’re accountable for the consequences. And I’m not keen on a victim’s mentality for those who are ill.

So far so good –

Last summer former Whole Foods CEO John Mackey offered an unsympathetic op-ed in The Wall Street Journal on the subject of health care reform. He provides the “correct” i.e. unedited version in the CEO’s blog:

Radiologist: Commoditize Thyself

Mar 28, 2011• 26

By DAVID E. WILLIAMS

There is little in the health care world as amusing as watching radiologists work themselves into a froth over some real or perceived threat to their profession. Usually the villain is non-radiologists daring to encroach on radiologists’ turf. See, for example, Radiologists pull out the long knives as the radiology community attacks self-referral by non-radiologists. But the latest story (JACR article fires broadside against teleradiology firms) is about radiologists going after one another.

Gentlemen, we have met the enemy, and he is us! I didn’t pay $30 to access the article itself, but instead refer to an extensive summary on AuntMinnie.

David Levin, MD, and co-author Vijay Rao, MD, of Thomas Jefferson University in Philadelphia, make their case that teleradiology outsourcing contributes to the commoditization of radiology, lowered reimbursement, displacement from hospital and outpatient reading contracts, greater encroachment by other specialties, and lowered quality.

Here’s the problem:

Radiologists have been content to live off the fat of the land, working bankers’ hours and outsourcing inconvenient night and weekend duties to teleradiology firms rather than taking call themselves. Even when they’re around, radiologists in general don’t do a good job of serving the physicians who refer to them, staying in their dark rooms and not being proactive or even responsive. As radiology groups are finding, if they demonstrate they’re not crucial to the success of a hospital on nights and weekends, that also makes a pretty good argument for why they’re not necessary during weekdays either. Once hospitals understand the truth they can dispense with the local, intransigent radiology group entirely.

Deciding What Works

Mar 28, 2011• 4

By STEVEN GOLDBERG

Steven Goldberg is probably best known for the controversial “Billions of Drops in Millions of Buckets: Why Philanthropy Doesn’t Advance Social Progress.” In this post he looks at the ways in which success and failure are measured in his field. Healthcare audiences will note many familiar themes. What should we measure? How should we measure it? How much weight should we give the results? And perhaps most importantly: what other questions should we be asking? — John Irvine

Conventional wisdom holds that randomized control trials (RCT) are the “gold standard” of evaluation. In fact, RCTs only make sense under very strict conditions that can rarely be met in the real world. Most of the time, RCTs produce inconclusive results and simply aren’t worth the time and money. As the social sector assumes greater responsibility for improving the lives of many more people, it should focus less on pseudo-scientific “proof” that programs work and focus more on making good programs better.

Now that the Social Innovation Fund (SIF) appears to have survived the “transparency” commotion, the eleven chosen intermediary grantmakers have less than six months to select their portfolios of nonprofit grantees.

As a commendable exercise in “evidence-based” grantmaking, SIF requires the intermediaries to incorporate evaluation into every step of their awards, from the initial competitive solicitations all the way through final payments and renewals. Applicants will be required to explain how their success should be measured and demonstrate their capacity to do so, and awards will be contingent upon the establishment of meaningful performance metrics, the timely collection and reporting of reliable data, and the faithful implementation of sound evaluation protocols.

A Patient is Not a Shunt

Mar 28, 2011• 24

By EVAN FALCHUK

Some people may tell you that health care IT will solve many of the quality and cost problems in health care.

I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus. Hydrocephalus is a build-up of fluid in the skull, which affects the brain. Among other things, people with hydrocephalus can be confused, irritable, and nauseous. Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.” This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid. You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared. But they soon started to re-emerge. Worried, his family took him to the hospital. Doctors found that his hydrocephalus was back – the shunt wasn’t draining properly. They admitted him to the hospital, and the next day they put in a new shunt. The surgery went well.

Life Saving Errors

Mar 26, 2011• 15

By DENNIS GRACE

On March 28, 1979 the Three-Mile Island Unit-2 nuclear power plant experienced a feed system failure which prevented the steam generators from removing heat from the plant. The reactor automatically shutdown but, without the feed system to cool the primary, the pressure in the primary system (the nuclear portion of the plant) began to increase. In order to prevent that pressure from becoming excessive, a relief valve opened. The valve should have re-closed once the pressure dropped by a small amount, but it didn’t. The only indication available in the control room showed the valve in the closed position, but that indication was erroneous, representing only that the signal to close the valve (pressure below a set value) had been sent to the valve. Nothing in the system verified the actual valve position. This stuck-open valve caused the pressure to continue to decrease in the system (and ultimately provided a path for spewing thousands of curies of radioactive material into the atmosphere), but the false shut indication prevented the operators from taking actions to mitigate their severe loss of coolant accident.

The primary relief valve design had a history of sticking. That same valve had been involved in at least nine other minor incidents prior to the TMI incident. Most notably, eighteen months before TMI, a similar incident had occurred in another nuclear plant involving a loss of feed and rising temperatures shutting down the plant. In that incident, the plant was just starting up after a maintenance shutdown, so the power level and temperature of the system were not as dangerously high as at Three-Mile Island.