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A Change in Tactics

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By ROBERT PRETZLAFF MD, MBA

Those that advocate for change in healthcare most often make their case based on the unsustainable cost or poor quality care that is sadly the norm. A 2018 article in Bloomberg highlights this fact by reporting on global healthcare efficiency, a composite marker of cost and life expectancy. Not remarkably, the United States ranks 54th globally, down four spots from 2017 and sandwiched neatly between Azerbaijan and Bulgaria. Unarguably, the US is a leader in medical education, technology, and research. Sadly, our leadership in these areas only makes our failure to provide cost-effective, quality care that much more shameful. For the well-off, the prospect of excellent accessible care is bright, but, as the Bloomberg article points out, as a nation our rank is rank. Anecdotally, I can report that as a physician I am called upon with some regularity to intervene on the behalf of family and friends to get a timely appointment or explain a test or study that their doctor was too busy to explain, and so even for the relatively well-off, care can be difficult and deficient.

The cost of care frequently takes center stage in arguments advocating change. The recognition that health care costs are driving unsupportable deficits and limiting expenditures in other vital areas is very compelling. Therefore, lowering the cost of care would seem to be an area in which there would be swift consensus. However, solutions to rein in costs fail to address the essential truth that most of us define cost subjectively. Arguments about the cost of care divide rather than unify as the discussion becomes more about cost shifting than controlling overall cost. Further, dollars spent on healthcare are spent somewhere, and there are many who profit handsomely from the system as it is and work aggressively sowing division to maintain the status quo.

Poor quality and access are additional lines of argument employed to win support for change. These arguments fail due to a lack of a commonly accepted definitions of quality and access to care. Remedies addressing quality and access issues are frequently presented as population level solutions. Unfortunately, these proposals do not engage a populace that cares first and foremost about their access to their doctor. The forces opposed to change readily employ counterarguments to population-based solutions by applying often false, but effective, narratives that population-based solutions are an infringement on a person’s fundamental freedoms. In that counterargument is the key to improving healthcare.

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Learning from CVS – When is telemedicine disruptive, and when is it just…cool technology?

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By REBECCA FOGG

The Theory of Disruptive Innovation, defined by Harvard Business School (HBS) Professor Clayton Christensen in 1997, explains the process by which simple, convenient and affordable solutions become the norm in industries historically characterized by expensive and complicated ones. Examples of disruption include TurboTax tax preparation software, which disrupted accountants, and Netflix, which disrupted retail video stores and is now giving Hollywood film studios a serious run for their money.

According to Christensen, a critical condition of disruption (but not the only one) is an “enabling technology”—an invention or innovation that makes a product or service (or “solution”) more accessible to a wider population in terms of cost, and ease of acquisition and/or use. For instance, innovations making equipment for dialysis cheaper and simpler helped make it possible to administer the treatment in neighborhood clinics, rather than in centralized hospitals, thus disrupting hospital’s share of the dialysis business.

However in an interview in Working Knowledge, the online newsletter highlighting HBS research, marketing Professor Thales Teixeira asserts that it’s not innovative technology that disrupts a market. Rather, it’s companies recognizing and addressing emerging customer needs sooner than incumbents. “…In many industries, both the disrupter and the disrupted had similar technologies and similar amounts of technology,” he points out. “The common pattern was that the majority of customers in those markets had changing needs and wants, and their behavior was changing.”

Well that’s interesting. Does Teixeira’s view on the role of technology in disruption, at least as summarized in the interview, contradict Christensen’s groundbreaking work? Not at all. In fact, Teixeira effectively reinforces an oft-overlooked nuance of the latter: disruption is not just about the innovative solution, no matter how novel, dazzling or slick the technology it may employ. It’s about using the solution to do a job for consumers that makers of incumbent solutions are ignoring—usually in a cheaper, simpler and more accessible way; and maximizing likelihood of success by aligning the innovator’s whole business model toward that end.

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Coronary Stent Price Control in India: Two Years and Counting

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By SOMALARAM VENKATESH MD

With a stated intent of bringing social justice and financial relief to hundreds of thousands of patients undergoing coronary angioplasty in the country every year, the Government of India capped the sale price of coronary stents in Feb 2017. Stent prices fell by as much as 80% with this populist move, seen as anti-trade within the industry circles. It is tempting for a practising interventional cardiologist to look at two years of this government control on medical device prices in a market economy.

Before price-capping, angioplasty patients were indeed getting a raw deal. There was no uniformity in price among stents of similar class/generation made by different manufacturers. The cost of the only bioabsorbable stent then available in India, to the patient, was 200,000 Indian Rupees (a little under USD 3000), whereas the US or European-manufactured (“Imported”) drug eluting stents (DES) would cost anywhere between INR 85,000 to 160,000. Stents manufactured within India (“Indigenous”) were cheaper. The real cost of manufacture or import was hidden from public view. It was left to the eventual vendor, with alleged involvement of the user hospitals, to determine the Maximum Retail Price (MRP). It was speculated that a huge margin was worked into it, and the profit was split between manufacturers, distributors, and hospitals. Allegedly, some unscrupulous physicians received kickbacks for implanting these devices. Even in government-run hospitals, foul play was suspected.

By a single stroke of the pen, Prime Minister Narendra Modi government slashed stent prices substantially. The bioabsorbable stent cost, to the patient, was capped at INR 60,000 (< USD 1000). Bare metal stents (BMS) and Drug-eluting stents (DES) were capped at INR 7500 and 30,000, respectively. The government seemed to have done its homework: these figures were arrived at from industry-supplied figures on manufacturing or import costs. The cosy network of coronary stent food chain was set on fire with this move: with sudden diminution of profit margins, it was feared that multinational companies would cut Indian workforce; stent distributors & vendors (especially small vendors) were expected to be wiped out or cut in size; doctors worried that with low profitability, multinational stent manufacturers would exit the country or at least, stop importing newer technologies; and hospitals feared revenue loss.

Following this, Industry and Hospital-chain representatives are said to have had series of discussions with the government. Rumours were that the Central Government was arm-twisting traders and that it would relent and raise price limits after these ‘talks.’ The National Pharmaceutical Pricing Authority (NPPA) promised a price revision, one year after the price cap. Meanwhile, some multinationals informed the government that they would withdraw some of their ‘top-end products’ from the Indian market, citing financial nonviability, obviously to put pressure on the government. The Bioresorbable Scaffold from Abbott actually disappeared from Cath lab shelves.

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Health in 2 Point 00, Episode 71 | Livongo’s SIGNUM 2019, Bobblehead Edition!

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Today on Health in 2 Point 00, Jess and I are at Livongo’s SIGNUM 2019 conference in San Francisco—in bobblehead form. In this episode, Jess asks me about my key takeaways from the conference, which focused on chronic condition solutions. It was really exciting to hear how the experience of patients with chronic conditions has been changed. We heard some fun stuff from Seth Stephens-Davidowitz about his book Everybody Lies and Daniel H. Pink’s When: The Scientific Secrets of Perfect Timing, and from Stephen Klasko of Jefferson University and Mark Ganz of Cambia Health about the importance of proper partnerships and innovation from traditional healthcare companies. At the end of the day, at a relatively small scale we’ve made a difference in the lives of people with chronic illness—but can we deliver this at a huge scale? —Matthew Holt 

“Public Charge” is a Public Health Disaster in the Making

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By PHUOC LE MD 

I was born in a rural village outside of Hue, Vietnam in 1976, a year after Saigon fell and the war ended. My family of four struggled to survive in the post-war shambles, and in 1981, my mother had no choice but to flee Vietnam by boat with my older sister and myself. Through the support of the refugee resettlement program, we began our lives in the United States in 1982, wearing all of our belongings on our backs and not knowing a word of English.

Though we struggled for years to make ends meet, we sustained ourselves through public benefit programs: food stamps, Medicaid, Section 8 Housing, and cash aid. These programs were lifelines that enabled me to focus on my education, and they allowed me to be the physician and public health expert that I am today. Looking back, I firmly believe that the more we invest in the lives and livelihoods of immigrants, the more we invest in the United States, its ideals, and its future.

So, when I first learned of the current administration’s plan to make it harder for immigrants with lower socioeconomic statuses to gain permanent U.S. residence, the so-called changes to the “Public Charge” rule, I felt outraged and baffled by its short-sightedness.
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Many Ways of Skinning a Statistical Cat

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By SAURABH JHA MD Saurabh Jha has a conversation with Professor Brian Nosek

In this episode of Firing Line, Saurabh Jha (aka @RogueRad), has a conversation with Professor Brian Nosek, a metaresearcher and co-founder of Center for Open Science.

They discuss the implications of this study, which showed that there was a range of analytical methods when interrogating the database to answer a specific hypothesis: are soccer referees more likely to give red cards to dark skinned players? What is the significance of the variation? Does the variation in analysis explain the replication crisis?

Listen to our conversation at Radiology Firing Line Podcast.

Consumers are Dishing On Healthcare Experiences—Be Part of the Conversation

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By KARYN MULLINS 

Consumers aren’t taking their healthcare providers’ words for it anymore. They’re taking charge and leading a digital revolution where individuals have the power to make their own educated decisions about care.

According to the Healthcare Consumer Insight & Digital Engagement report by Binary Fountain, a leading online reputation management platform, 51 percent of people who have a physician share their personal healthcare experiences via online ratings, review sites and social media.

Once shared, this information is immediately available to the entire world with just the click of a button. And people are taking full advantage of this. In fact, 80 percent of respondents in the 2018 Customer Experience Trends in Healthcare report by Doctor.com have used the internet to make a healthcare-related search in the past year. Another 81 percent said they read reviews about a referred provider.

Consumers’ accessibility to detailed, personalized experiences could make or break medical sales companies. Unfortunately, if these trends aren’t addressed appropriately, medical sales teams around the country will feel the impact.

By further empowering the general public, medical sales leaders can give their teams the tools needed to excel in the field. Here’s how:Continue reading…

EMRs, APIs, App stores & all that: More data

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By MATTHEW HOLT, with OLIVIA DUNN & KIM KRUEGER

Today I’m happy to release an update to some unique data about a pressing problem–the ability of small health tech vendors to access data from the major EMR vendors and integrate their applications into those EMRs. For those of you following along, in 2016 when Health 2.0 first ran this EMR API survey, we confirmed the notion that it’s hard for small health technology companies to integrate with the EMR vendors. Since then the two biggest vendors, Epic & Cerner, have been much more aggressive about supporting third party vendors, with both creating app stores/partnership programs and embracing FHIR & SMART on FHIR.

In 2018, we conducted a follow-up survey to see if these same issues persisted and how much progress has been made. In this report, we break down the results of the 2018 survey and compare them to the results of our 2016 survey. As in 2016, survey response rates weren’t great, but in this year’s survey we asked a lot more questions regarding app store programs, specific resources accessed, troubling contract terms and much more. And if you look at the accompanying slides, we also pulled some juicy quotes.

The key message: In 2016 we said this, The complaint is true: it’s hard for smaller health tech companies to integrate their solutions with big EMR vendors. Most EMR vendors don’t make it easy. But it’s a false picture to say that it’s all the EMR vendors’ fault, and it’s also true that there is great variety not only between the major EMR vendors but also in the experience of different smaller tech companies dealing with the same EMR vendor.

In 2018, things are better but not yet good. A combination of government prodding (partly from ONC implementing the 21st Century Cures Act, partly in the continued growth of pay for value programs from CMS), fear of Apple/Google/Amazon, genuine internal sentiment changes at least at one vendor (Cerner), and maturity in dealing with smaller applications vendors from three others (Allscripts, Athenahealth, Epic), and the growth of third party integration vendors like Redox and Sansoro, is making it easier for application vendors to integrate with EMRs. But it’s not yet in any way simple. We are a long way from the all-singing, all-dancing, plug-in interoperability we hoped for back in the day. But the survey suggests that we are inching closer. Of course, “inching” may not be the pace some of us were hoping to move at.

All the data is in the embedded slide set below, with much more commentary below the fold.

Health 2.0 EMR API report 2018

It’s getting better but….EMR Vendors are still a bottleneck
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Saying No to the Drug Crisis

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By BRIAN KLEPPER

In a recent essay, VIVIO Health’s CEO Pramod John guides us through four sensible drug policy changes and supporting rationales that could make drug pricing much fairer. Reading through it, one is struck by the magnitude of the drug manufacturing industry’s influence over policy, profoundly benefiting that sector at the deep expense of American purchasers. As Mr. John points out, the U.S. has the world’s only unregulated market for drug pricing. We have created a safe harbor provision that allows and protects unnecessary intermediaries like pharmacy benefit managers. We have created mechanisms that use taxpayer dollars to fund drug discovery, but then funnel the financial benefit exclusively to commercial interests. And we have tolerated distorted definitions of value – defined in terms that most benefit the drug manufacturers – that now dominate our pricing discussions.

The power of this maneuvering is clear in statistics on health industry revenues and earnings. An Axios analysis of financial documents from 112 publicly traded health care companies during the 3rd quarter of 2018 showed global profits of $50 billion on revenues of $636 billion. Half of that profit was controlled by 10 companies, 9 of which were pharmaceutical firms. Drug companies collected 23% of the total revenues during that quarter, but retained an astounding 63% of the profits, meaning that the drug sector accounts for nearly two-thirds of the entire health care industry’s profitability. Said another way, the drug industry reaps twice the profits of the rest of the industry combined.

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Health Care-Related Public-Private Partnerships Will Likely Become the Norm in 2019

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By MARY SCOTT NABERS 

The United States ranks number one in the world for health care spending as a percentage of GDP. That sounds great… but, for instance, Texas ranks only 11th worldwide when it comes to performance. That’s because of access to care.

The country’s health care rankings are likely to get worse as 673 rural hospitals in the U.S. are at risk of closing. Here’s what has happened: the need for care greatly outpaces available funding, especially for public hospitals. Something must be done.

If public funding is no longer available, alternative funding can be secured in numerous ways. The simplest way to access alternative funding is through a public-private partnership (P3) engagement. However, alternative funding for public hospitals, health care clinics and university medical centers can be found from other sources as well. Finding funding is not a problem when private-sector investors, large equity funds, pension programs, asset recycling and EB5 programs all stand ready to invest in public-sector projects.

Moving to a P3 health care model would allow hospitals to secure immediate funding and utilize private-sector expertise and best practices while transferring all risks. The launch of health care P3s would also ensure new construction, new jobs and hundreds of additional health care options for people.
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