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Simon Nath

Texas Abortion Case Isn’t about Abortion, but The Rule of Law

Whole Woman’s Health v. Cole, the Texas abortion case that is now before the Supreme Court, is really about the rule of law and how federal judges maintain it by holding states to external standards. The case follows Planned Parenthood of Southeastern Pa. v. Casey, which forbade states from using the desire to protect women’s health as a pretext for curtailing their access to abortion services. But how is a judge to distinguish a pretext from a genuine concern for patient safety?

Casey seemed to say that unless all possible connections between a regulation and patients’ wellbeing can be ruled out completely, a state’s proffered reason is bona fide. That’s far too weak a standard, and later cases seemed to confirm it by saying that states don’t have to show that their laws will actually protect women from documented perils. Seeing this, Texas and other pro-life states have done exactly what Casey forbids. They’ve enacted laws that shut down abortion clinics while shouting “Women are in danger! Women are in danger!” The issue in Cole is whether states must prove that access-impeding laws address real safety problems. If the Court says no, Casey will be a dead letter.

It should be plain to everyone that lawmakers won’t respect constitutional limitations on their own. Politics is a brass-knuckles world. The people who thrive in it aren’t rule-followers by nature, and their incentives are terrible. When they can gain by doing something, they will, the Constitution be damned. That’s where judges come in. They’re supposed to keep lawmakers in line by delivering swift kicks to their posteriors when they violate the Constitution.

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Surgeons Doing Math

I bought a car as a package. It had wipers and tires and brakes. The car dealer gave me a simple price after he added the costs of components and labor plus profit. I wanted to buy surgery as a package. I wanted a surgeon and anesthesiologist and facility. There was no dealership for surgery packages, so I asked a facility to put one together. “Add sutures and gloves and some graspers,” I pleaded, “please, I have to have choice.”

Turnkey surgery packages are hard to find. That is partly because most surgery is paid for in separate fees for separate services by faceless third parties that take the patient’s money, dictate his choice, and keep price largely hidden behind a bureaucratic curtain. So why can’t a facility just put a surgery package together? Doesn’t the arithmetic of tires work just as well on sutures?

Consider the facility executive: he has no real subject expertise. For example, he rarely knows the difference between a nylon and chromic suture. He is also not used to costing and packaging, because he has had little incentive. This is because there has for decades been little market for simply priced packaged services. The big market for surgery is fee-for-service. To integrate a simply priced surgery package into legacy fee-for-service systems would require technical effort. Simplicity is complicated.

There is a second issue: legacy structures have brought atrophy to healthcare accounting. Paternalistic third parties allow payment of specific amounts and thus render informedactivity based costing and rational cost-plus-margin pricing irrelevant. The executive’s costs and profit don’t matter because his allowance has been set by another.

These are two of the reasons behind our wasteful excess capacity. Think about it. If the executive with little subject expertise indexes his price to third-party allowable, which is common, and those allowables are lower than true cost, the facility would subsidize care. If the executive indexes to third-party allowable and those allowables are higher than is marketable, the facility may sell nothing. Both propositions are losers for the facility and its patients.

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As health IT Matures, Security Approaches Must Mature With It

Not that long ago, healthcare worried mostly about the physical loss of personal health information (PHI) by way of a lost thumb drive, a stolen laptop, some misplaced paper files. These were the primary concerns in HIMSS initial security survey, published in 2008. It wasn’t until five years later, in 2013, that the largest healthcare security breaches came from cyberattacks instead of lost or stolen devices.

So, is it encouraging to see how far the rapid pace of change has carried health IT in just a few years? Well, yes and no. Growth is good, but it always presents a new set of challenges.

To be sure, healthcare has joined the rest of the wired world as a frequent target of technically skilled ne’er-do-wells. In 2014, cyber breaches in the form of systems hacking, credit card skimming and phishing (obtaining sensitive personal data by pretending to be someone trustworthy) totaled 29 percent of all security breaches. In 2015, that number rose to 38 percent.

Expect the trend to continue.

And expect it to get more complicated based on what’s happening in other industries. You may, for example, remember an interesting experiment last summer in which hackers demonstrated the susceptibility of a car’s onboard computer system by taking control of a Jeep going 70 miles per hour on a freeway outside St. Louis.

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How do Consumers view Technology’s Role in Healthcare?

As technology-enabled home health becomes more pervasive, how will consumers respond? What concerns and reservations will they have? Will they readily adopt new technologies? Deloitte conducted focus group research to better understand consumer expectations and preferences for receiving health care services in the future, focusing on care in the home.

In general, consumers are optimistic: To them, the benefits of technology-enabled home health far outweigh the risks, and they are eager to try it. For the unwell, home health technology can help manage their conditions and slow disease progression. For caregivers, it can offer peace of mind. For the healthy, it can provide the tools and support to maintain healthy behaviors.

Even though interest is high, we heard some concerns. Consumers value the personal nature of health care and the patient-doctor relationship. Many are concerned that increasing reliance on technology will erode the relationships that they feel are already threatened by the fragmented nature of health care, decreasing face time with doctors, and difficulty establishing and maintaining those meaningful relationships. While it may seem obvious that technology should reinforce and facilitate relationships rather than supplant them, consumers’ previous experiences with technology temper their enthusiasm.

Technology-enabled solutions that are perceived to intrude on people’s privacy, such as sensors that monitor an individual’s sleep quality or motion patterns at home, face resistance. Education may be required to effectively convey the benefits of such monitoring; consumers are then able to evaluate the pros and cons, and many are amenable to the tradeoff.

As more care moves to self-care, consumers want to have influence and control over their own care and health information. They expect to learn about new technologies and to be actively involved—as patients or caregivers—in deciding which technologies are used for their care, how they are used, and what data will be disclosed and shared.

Companies—whether newcomers or traditional players—developing the technology for home health are expected to negotiate a number of challenges:

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How I Use P4 Medicine to Maximize Patient Engagement

The healthcare industry is changing as new models of care and reimbursement emerge. One of these approaches is P4 Medicine. P4 Medicine stands for predictive, preventive, personalized, participatory. This approach deeply resonates with me because the philosophy is aligned with how I have been developing my medical practice, which is focused on optimizing health and avoiding disease. In my opinion, P4 Medicine is one of the best models for maximizing patient engagement.

The earliest manifestation of P4 Medicine began eight years ago at the Institute of Systems Biology when Dr. Lee Hood, MD, PhD, a physician scientist and creator of the automated gene sequencer, recognized that the application of systems biology to medicine would fundamentally alter our understanding of health and disease. This model has merged three powerful aspects of science and technology:

  • Systems biology (defined as the study of biological systems as collections of networks at multiple levels, ranging from the molecular level, through cells, tissues and organisms, to the population level)
  • The digital revolution (e.g., big data and analytics, wearable technology, mobile technology, etc.)
  • Consumer-driven healthcare (e.g., patient/consumer activated social networks)

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Why Healthcare IT is So Hot Right Now

screen_shot_2015-09-02_at_3.50.13_pm_0It’s 8:15 on Friday evening.  I’m almost through editing the job description for a user interface engineer after sending off an introductory slide deck to a potential client.  Today I met with a business development prospect, held calls with a potential advisor, a potential client, finally made those changes to the website.  There’s not time to write this but when will there be?

I’m part of a growing trend of academics, programmers, and clinicians taking the startup path to try to make healthcare a better place. In fact, record breaking amounts of venture funding are pouring into healthcare with 2014 seeing $4.13 billion in digital health venture funding and 2015 showing no signs of slowing.  Established tech companies not typically associated with healthcare including Apple, Samsung, and IBM are getting in on the act with enormous investments.  It seems that nearly every hospital and insurer is launching its own incubator or innovation fund.

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Yelp Can Help: Rating Access to Electronic Medical Records will Hold Hospitals Accountable

Niam YaraghiWhile patients may hugely benefit from having access to their own medical records, many hospitals and physicians are still very reluctant to provide patients with a copy of their records.

Although taxpayers have partly paid for the majority of hospitals to adopt electronic health records systems, which reduce the cost of reproducing medical records to effectively zero, some of them continue to charge patients exorbitant fees for access to their records. While imposing these charges is against the Health Insurance Portability and Accountability Act (HIPAA) regulations, some medical providers take advantage of patients’ unfamiliarity with such regulations and use HIPAA and patient privacy as excuses to avoid releasing patient records.

Now, in an unprecedented lawsuit against MedStar Georgetown University Hospital and George Washington University Hospital, three patients are seeking class-action status, saying they were charged hundreds to thousands of dollars for a copy of their electronic medical records.

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New Breast Cancer Screening Guidelines Could Backfire

Lianne PhilpottsLast week the American Cancer Society (ACS) released new breast cancer screening guidelines. There has been mixed reaction to these guidelines, which recommend less screening – mammography starting at a later age (45 years old) and less frequent (every two years after age 55). Those who are mammography skeptics applaud this ‘less is more’ approach. But those who feel early detection is the best way to prevent deaths from breast cancer, are defending that annual mammography from age 40 on is best. Yet another battle in the mammography war has started!

With the increased emphasis on personalized medicine, the new guidelines can be viewed as a small step in that direction. Not a ‘one-size-fits-all’ recommendation, but tailored to the patient’s age. This is reasonable. Yet the ACS acknowledges that annual screening yields a better mortality reduction than biennial and that all women over 40 should have access to annual mammograms. How is that going to work? Guidelines are supposed to guide – these leave it up in the air.

What are breast imagers supposed to tell the over-55 patients? Come back in 1… or 2 years? Or not give any recommendation and leave it up to the patient and her physician to decide? What are the medico-legal ramifications? If a woman over 55 who adheres to biennial screening feels she could have had her cancer detected earlier, will she sue her doctor for not recommending annual? Will most women and physicians really have an in-depth discussion of the risks and benefits of screening on an individual level? The responsibility on the referring physicians will be great.

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athenahealth presents

Providers are fed up with interface fees and the lengthy, fragmented narratives we’re exchanging today. But what is the right course of action to help deliver better care across the continuum? Join Beth Israel Deaconess CIO Dr. John Halamka and athenahealth CEO Jonathan Bush to discuss the current state of health care and how we can improve care coordination and interoperability.

RSVP today.

John D. Halamka, MD, MS, CIO

John D. Halamka, MD, MS, is Chief Information Officer of the Beth Israel Deaconess Medical Center, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), Co-Chair of the HIT Standards Committee, and a practicing Emergency Physician.

Jonathan Bush, CEO, athenahealth

Jonathan Bush co-founded athenahealth, Inc. in 1997 and is the author of New York Times best-seller Where Does It Hurt? An Entrepreneur’s Guide to Fixing Health Care.

About the Series

Spend an hour in conversation with medical professionals at the forefront of health care today. Join athenahealth CEO Jonathan Bush for thought-provoking interviews—and bring your own questions to the table—in these exclusive live webinars. Reserve your place today.

Neither Expert nor Businessman: The Physician as Friend

Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

“With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!

Perhaps sensing the difficulty of their position, Sullivan and Ellner conclude the article on a more sober note:

If we believe that relationships are key to value, how should we be measuring them? The good news is that we have role models: Some practices are already doing this. The bad news is that each one is different, specific to its patients’ and community’s needs. But maybe that’s not so bad. After all, every relationship is different.

Yes, “every relationship is different,” and for the most part, healthcare economists and policy makers have paid scant attention to the doctor-patient relationship except in two opposing respects.

On the one hand, Nobel Prize winner Kenneth Arrow and his followers have emphasized the “asymmetry of information” between doctor and patient. According to them, the lopsidedness between the knowledge of doctors and the ignorance of patients is so great as to render patients helpless. Government must intervene in the healthcare market to redress the imbalance of power.

On the other hand, and against the paternalism of Arrow’s view, a “consumer-driven healthcare” movement has emerged according to which patients should have more choice in the kind of care they receive. This choice will occur if patients manifest greater financial responsibility in their medical care through the use of health-savings accounts and high-deductible health insurance. With such measures, it is argued, healthcare would behave more like a free market, costs would decrease, and quality would improve.

While both models seem at odds with one another, both commit the same conceptual error of considering that the primary function of the doctor is to supply an objective service. Hence, neither school has any qualms with identifying the doctor as a “provider.”

But to limit medical care as a “provision” of services greatly misunderstands the complex reality of the therapeutic relationship.

Almost 60 years ago, Szasz and Hollender pointed out that there are three aspects to the doctor patient-relationship: activity-passivity (doctor does “something” to patients); guidance-cooperation (doctor tells patients what to do); mutual participation (doctor helps patients help themselves).

All three aspects are operative, but one may dominate the others depending on the particular circumstances at a given time.

Accordingly, a cardiologist may be “doing” a coronary stent at one point, yet for months prior to that she may have been—perhaps begrudgingly—cooperating with the patient’s desire to avoid taking a statin. And she may spend the next years coaching the patient on best ways to cope with statin-induced muscle pains and to adjust to difficult dietary restrictions.

Of course, all these aspects of care are rendered with great uncertainty as to the particular patient’s ultimate outcome, and parsing the importance of each aspect of care in relation to an uncertain outcome is anyone’s guess.

The first aspect of the doctor-patient relationship (the “activity-passivity” mode) is the only one that policy makers and health economists typically consider, precisely because it involves a “something” that doctors do to patients. That something can (theoretically) be objectively observed, analyzed—and measured by third parties. But in ignoring the other two aspects of the relationship, one inevitably distorts the whole picture of what healthcare is about.

And Szazs and Hollender’s account of the therapeutic relationship may even be too simplistic. Yes, doctors do things to patients, guide them, or help them help themselves. But they may also humor them, scold them, or ignore them altogether, and each action may be appropriate in its own context.

And conversely, patients act on doctors. They can show gratitude (in a variety of ways), and thus enrich them on a personal level. But they can also question them, challenge them, refuse their advice, and keep them on the straight-and-narrow, all-the-while remaining committed to that relationship despite any limitation they may perceive about the care they are receiving.

In truth, a good therapeutic relationship is precisely undergirded by this mutual commitment, where the one will not abandon the other for failing to follow through with the prescribe course of action, and the other will not ditch the one for failing to “deliver” outcomes everyone knows are unpredictable.

Relationships based on commitment are neither captured by the expert-subject model, which primarily focuses on the skills and science of the all-knowing physician, nor by the businessman-customer model, which focuses on how physicians can aim to please patients.

No, the committed therapeutic relationship is truly one of friendship. And any person, entity, or policy that overlooks the friendship aspect of medicine is sure to inhibit, if not altogether destroy, the essence of what good medical care is all about.

Will outcome enthusiasts take stock of the likely outcome of their own enterprise?

Michel Accad is a cardiologist based in San Francisco.