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Simon Nath

Employer Sponsored Insurance: Unfair and Unaffordable

flying cadeuciiFor all those Americans faced with higher health insurance premiums or less coverage (that’s most of us), the temptation is to blame the Affordable Care Act. Maybe instead we should be blaming the one thing the ACA didn’t significantly change: employer sponsored insurance—the norm for most working Americans.

Although the ACA imposed some new standards for coverage, ESI employers remain free to dictate most insurance details, the tax-exclusion of ESI benefits is largely unchanged, ESI premiums are still generally independent of income, and small employers can still offer ESI or not.

Unfortunately for millions of workers, it’s a model that’s increasingly neither affordable nor equitable. What seemed a reasonable approach fifty or sixty years ago when healthcare costs were far lower is now one of the most regressive health insurance systems in the industrialized world.

The Kaiser Family Foundation’s most recent employee benefits report demonstrates the problem.

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Enduring Effects of Trauma in Newtown and Beyond

This month’s Sundance Film Festival, a 10-day salute to movies that are often hailed as tapping into the national zeitgeist, have two films this year on gun violence: Katie Couric’s “Under the Gun” and Kim Snyder’s “Newtown.” Both will be screened by influential audiences this week with a plan for larger distribution over the year. And both will no doubt question what we as Americans should do to prevent mass shootings and to heal afterward.

The ripple effects of mass shootings are immense. Earlier this month school leaders in Newtown testified to Connecticut’s state board of education about the ongoing mental health difficulties that children in Newtown are having three years after the massacre at Sandy Hook. As a trauma psychologist and a pediatrician, we were saddened, but not surprised, by this report. Working in New Haven, just 20 miles from Newtown, we both have colleagues and patients who are in those concentric circles of Sandy Hook and have felt the effects in our professional and personal lives. As health care professionals, mothers, and neighbors of Newtown, we wondered what we as a nation have learned about long-term healing ­in places like Columbine and Virginia Tech.

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Why Are Physician Engagement Scores So Dismal?

GundermanMany hospitals around the nation have been stung by dreadful physician engagement scores. Engagement is a problem not only for demoralized physicians, but for healthcare organizations, their employees, and everyone they serve. They should take note, because low levels of engagement are associated with higher physician turnover, increased error rates, poorer rates of patient cooperation in treatment, and lower levels of patient satisfaction.

Definitions of engagement vary, but it generally includes pride, loyalty, and commitment. When engagement scores are low, physicians take little pride in the hospital, would not recommend it to a job-seeking colleague, and believe that the hospital’s mission and vision are not in sync the needs of patients. On the other hand, engaged physicians are more likely to perform better in every area, including patient care, education, and research, which benefits everyone.

To better understand the roots of poor physician engagement, I recently sat down for a conversation with a large group of students from the Indiana University Kelley Business of Medicine MBA program. Its students are practicing physicians from around the country who have realized that to improve patient care they need to become better leaders. Many work in hospitals that have identified engagement challenges and are attempting to develop solutions to the problem.

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Data Parasites?

flying cadeuciiIn just four years, it seems, data science has devolved from the “sexiest job of the 21stcentury” to a community of “research parasites.”

The latest assessment is courtesy of an editorial in the New England Journal of Medicine (NEJM), written by editor-in-chief Jeff Drazen, along with Dan Longo.

Essentially, Longo and Drazen argue that while the Platonic ideal of rich data sharing is lovely, reality is not so pretty.

First, Longo and Drazen allege, researchers who weren’t involved in gathering the original data often lack essential appreciation for how it was gathered, and thus may misinterpret it, as they “may not understand the choices made in defining the parameters.”

Second–and this is really the heart of the issue–Longo and Drazen worry that a new class of research person will emerge—people who had nothing to do with the design and execution of the study but use another group’s data for their own ends, possibly stealing from the research productivity planned by the data gatherers, or even use the data to try to disprove what the original investigators had posited. There is concern among some front-line researchers that the system will be taken over by what some researchers have characterized as “research parasites.”

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The Patient-Centered Health Record

The other night I participated in a very useful Google+ hangout with Adrian Gropper, Michael Mascia and Michael Chen. The discussion focused on a subject I think is incredibly important: the patient-centered health record. Unfortunately, this topic is hard to discuss without drowning in technical terms and acronyms. I consider myself fairly tech-savvy and still struggle.

A (55 minute) YouTube video is here: Click here

I think it is worth watching. before watching it, consider reviewing the following basic information to help set the stage, first without tech terms or acronyms, and then repeated with some of the key jargon.

The current EHR model is that each office or institution owns and manages an electronic record that contains information about the patients in that system. Despite the obvious need and lots of talk, there has been little actual progress towards making these separate and mostly proprietary systems ‘interoperable’ and therefore able to share information. The result is that clinicians routinely work with incomplete or outdated information, patients are locked into their home system, and it is extremely hard for patients to access their own information in any meaningful or useful way. Care is less safe and less reliable, patients are prevented from actively managing their care, and clinicians are frustrated.

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Will the Pharmaceutical Industry Learn From Past Mistakes?

Soeren MattkeAwash in negative headlines, public condemnation and government scrutiny, the pharmaceutical industry faces a public relations problem that, left untreated, could bring new regulations or sanctions either from governments or the courts. At the same time, though, the recent scandals over price gouging could offer an opportunity for responsible, research-based companies to distance themselves from the profiteers.

The industry has come under fire at a time of unprecedented innovation. As a physician who trained in the 1990s, I am in awe of the recent breakthroughs. Immuno-oncology drugs like Keytruda (pembrolizumab) and Opdivo (nivolumab) offer hope for patients with previously untreatable cancers. Entresto (sacubitril/valsartan) – the first novel treatment in over a decade for congestive heart failure, a condition deadlier than most cancers – was approved this year. There is a cure for many forms of Hepatitis C with Sovaldi (sofosbuvir) and vaccines for dengue fever and maybe even malaria may become available soon. More patients in developing countries than expected have access to antiretroviral drugs for HIV/AIDS and companies are devoting resources to achieving the same for the new scourge of noncommunicable diseases.

At the same time, some in the industry have been seeking to tackle the image problems. Overeager sales representatives are being reined in. Financial ties to physicians and clinical trial data are being disclosed. The main industry bodies in the United States, PhRMA and BIO, disowned Turing Pharmaceuticals, the company behind the notorious 5,000 percent price increase for Daraprim, a critical drug for certain infections in immunocompromised patients.

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The Unaffordable Care Act

Liberal public health advocates and left-of-center health policy wonks have long thought every American needs health insurance (they don’t, but that’s another discussion). Lefties assume health insurance is the only way Americans access medical care. After all, the purpose of the Affordable Care Act was to insulate Americans from the financial hardship of medical care they couldn’t afford to pay for out of pocket. Moreover, many pundits believe having to reach for one’s wallet during a medical encounter is unacceptable. So imagine my shock when I read a headline in  The New York Times claiming that Obamacare is no guarantee against crushing medical bills.

In a survey of non-seniors, the New York Times/Kaiser poll found about one-in-five people struggle with medical bills even though they have insurance. Among insured people who reported crushing medical debts, about three-quarters reported putting off vacations, major purchases and cutting back on household spending. Nearly two-thirds used up all or most of their savings. Far fewer had to resort to second jobs, take on more hours or ask family members for funds (42 percent to 37 percent).

Why are these insured Americans having to reduce their standard of living and, in fewer instances, having to resort to more drastic measures? Was it entirely because they’re sick? A common refrain among those struggling with medical bills was that money was tight prior to a family illness. This includes high-income households as well as low income households.

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Is Health care Ripe for Disintermediation?

Ashton KutcherWhat do Ashton Kutcher, Donald Trump and Travis Kalanick have in common? They recognized an opportunity and used it to their advantage. That trend: disintermediation—the opportunity to deliver a product or service to a consumer with higher perceived value than an incumbent’s by changing the fundamental way it is delivered.

  • Kutcher made a major investment in Brian Chesky and Joe Gebbia’s start-up. The trio recognized that hoteliers who gouge patrons around peak events like the Super Bowl or conventions are vulnerable. They created Airbnb that provides overnight guests accommodations in private homes at half the price of a hotel’s rate. But Airbnb doesn’t own or operate a hotel room anywhere.1
  • Trump recognized that 70% of American voters say they’re independents or moderates and do not align with either party. Thus, he’s leading the GOP pack by appealing directly to voters while skirting traditional conventional campaigning and the traditional ground game in politics. And his style of straight talk and disdain for political correctness has tapped into a segment of public disdain for traditional politicians.2
  • Kalanick concluded that urbanites wanted convenient transportation service and millions who have cars wanted part-time income. With a $60 billion market cap after five years of operation, Uber is history’s most successful IPO. But Kalanick doesn’t own a fleet of taxis. 

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Toyota-ism vs Taylor-ism

flying cadeuciiIf you’re new to the idea of “Lean,” I invite you to download and read chapter 1 of my book Lean Hospitals.

Hat tip to Suresh for pointing me toward this article that was just published January 14th in the New England Journal of Medicine: “Medical Taylorism

NEJM is the same journal that published Dr. Don Berwick’s article about Kaizen and Dr. Deming in 1989, how those concepts would be helpful in healthcare. Dr. Berwick realizes, as he talks about in that article, that not all factories are the same. Some are managed better than others. Employees are treated better in the “Lean” factories. Berwick was right to point out that medicine can learn from other industries… but that doesn’t turn the hospital into an assembly line.

In the article posted this week, Pamela Hartzband, M.D., and Jerome Groopman, M.D. (the later the author of the popular book How Doctors Think), rant about all sorts of things… some of which have nothing to do with Lean.

“Advocates lecture clinicians about Toyota’s “Lean” practices, arguing that patient care should follow standardized systems like those deployed in manufacturing automobiles. Colleagues have told us, for example, that managers with stopwatches have been placed in their clinics and emergency departments to measure the duration of patient visits. Their aim is to determine the optimal time for patient-doctor interactions so that they can be standardized.”

This is wrong headed and insulting toward Toyota. I’m pretty sure Toyota would not alienate physicians or other healthcare professionals this way.

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Posts on EHRs, Data and Patient Safety


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