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Simon Nath

The Case for Case-Based Reasoning

flying cadeuciiCase-based reasoning has been formalized for purposes of computer reasoning as a four-step process[1]:

  • Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.
  • Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.
  • Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.
  • Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

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The Healthcare Data Sharing Conundrum

flying cadeuciiPeople are more likely to avoid loss than to seek gains. HIPAA creates a framework where it rewards risk adverse behavior for data sharing even when data sharing would ultimately be beneficial to the enterprise, the mission, and the patients. This is a general issue at the heart of making progress in healthcare regarding data sharing and interoperability. I have some new thoughts on how to bridge this divide.

Recently I read the book ‘Thinking, Fast and Slow’ by the Nobel Prize winning economist Daniel Kahneman. This book discusses the concept of Prospect Theory. In reading through it I could see a hint of why our industry has so much trouble trying to share medical records and in general has trouble sharing almost anything among trading partners and competitors. If you haven’t read about Prospect Theory, the following tests provide some of the basics into how humans make decisions about risk.

Decision 1: Which do you choose? Get $900 for sure OR 90% chance to get $1,000

Decision 2: Which do you choose? Lose $900 for sure OR 90% chance to lose $1,000″[i]

The common answer to #1 is to take the $900. The common answer to #2 is to take the 90% chance to avoid the loss. As a result, we take risks to avoid danger but avoid risks when we see certain rewards. This behavior is relevant to data sharing and access to PHI and can be instructive on how people will approach risk.

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Patient-Centered Service

flying cadeuciiAmerican healthcare has a customer service problem.  No, customer service in the US is terrible when it comes to healthcare.  No, the customer service in the US healthcare system is horrendous.  No, healthcare has the worst customer service of any industry in the US.

There.  That seems about right.

What makes me utter such a bold statement?  Experience.  I regularly hear the following from people when they come to my practice:

  • “You are the first doctor who has listened to me.”
  • “This office makes me feel comfortable.”
  • “I didn’t have to wait!”
  • “Where’s all the paperwork?”
  • “Your office staff is so helpful. They really care about my needs.”
  • “This is the first time I’ve been happy to come to the doctor.”
  • “It’s amazing to have a doctor who cares about how much things cost.”
  • “You explain things to me.”
  • “You actually return my calls.”

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The Transparency Trap

flying cadeuciiOn a recent shift in the Emergency Department, a resident boasted to me that she had convinced a patient to have an MRI done after discharge, rather than in the hospital. She was proud of this achievement because MRIs cost much more in the hospital than they do elsewhere – sometimes thousands of dollars more. To advocates of “cost-conscious care,” a new movement in medical education that aims to instill in young doctors a sense of responsibility for the financial consequences of their decisions, this story seems to belong in the ‘win’ column.

But this story also raises troubling questions: Why wasn’t the resident more concerned about how the hospital’s charging practices were leading her to delay care for her patient? What about the prolonged anxiety the patient would suffer? What about the extra day of work she would have to miss? And most importantly, why does an MRI cost thousands of dollars more in the hospital than it does across the street?

Like many doctors, she had fallen into the ‘transparency trap.’ This phenomenon is an unintended consequence of price transparency efforts that have come in response to patients and doctors being kept in the dark for decades about the prices of common services. Unfortunately, as the CEO of one large hospital put it, “the vast majority of [prices] have no relation to anything, and certainly not to cost.” In fact, studies have shown that in a functional market, MRIs would cost somewhere around $250, and we wouldn’t be nearly as concerned about doing too many of them.

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The Unaffordable Affordable Care Act Turns 6

This week marks the sixth anniversary of the Patient Protection and Affordable Care Act (ACA). But it’s hardly anything to celebrate. The ACA was intended to make health coverage affordable using an age-old strategy referred to as OPM (other peoples’ money). For instance, ACA regulations require insurers to accept all applicants — including unprofitable ones — at rates not adjusted for their health risk. Premiums can vary somewhat based on age, but not health status. A plethora of new taxes (mostly on medical care and health insurance) are supposed to somehow make coverage more affordable. Other funding mechanisms include draconian cuts to Medicare and higher deficits to expand Medicaid.

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The Narrowing of the Network

The concept of restrictive (oh let’s call them euphemistically “narrowed”) networks has for decades been the third rail of healthcare. Ask Hillary Clinton, who put her foot on that third rail in the 1990’s while attempting to reform healthcare. In the same vein, HMOs in the 90’s also tried to restrict networks, resulting in vicious backlashes.

One of those backlashes was the enactment in many states of so-called “any willing provider” or “freedom of choice” legislation. At last look, some 27 states still have a form of such legislation on their books. Most credible studies show that such laws increase the cost of healthcare.

Moreover, the ability of insurers to remove physicians from their network in many states is severely restricted by so called “fair hearing” legislation that makes the pain of achieving physician expulsion worse than the pain of leaving under performing physicians in network.

We understand that when a physician cries “foul” against an insurer, public sentiment will favor the physician, and over the years, it certainly has been  reflected in this and other legislative attempts to tie insurers’ hands.  After all, no one wants to go to the prom with a health insurer.

As a result of this and other phenomina, there has been the highly chronicled swoop toward mediocrity in the delivery of healthcare in the United States. And insurers have certainly contributed here. Up to now, insurers have paid physicians using the fee for service payment method. This method merely requires physicians to demonstrate that they performed a function, at which point they are paid at an amount that does not vary regardless of quality or outcome. This is a completely volume driven environment with predictable results.

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The ACA at 6 Years: Solid Progress but Cost Issues Remain

flying cadeuciiThe Obama Administration this month released final numbers on enrollment for the 2016 coverage year in the health insurance exchanges, as well as overall statistics on coverage gains to date under the Affordable Care Act (ACA).

The numbers emerge as the ACA turns 6 years old this week—on March 23. They were also released just as House Republicans issued their proposed 2017 federal budget. That budget, once again—you guessed it—repeals the ACA. The Republican budget is a counter to the Administration’s budget proposed in February. The release of both triggers the annual bruising battle over funding of the federal government, which again this year could end in prolonged stalemate.

You could be cynical or blasé about the Republicans’ persistent mission to kill the ACA—that is, if you don’t support that mission. But I think this piece of political theater continues to warrant contempt. Why? Because even if a Republican were elected President in November, the law is now technically impossible to gut completely. And Republicans know it.

There are a host of reasons the law cannot be nixed in its entirety, and these deserve more attention and discussion, on THCB and elsewhere, at a later time. In the context of this blog, I’ll just point out the obvious: it would simply be unacceptable (and political suicide) to strip 15 to 20 million people of their coverage. In addition, realistically, any insurance scheme to replace Obamacare would very likely be structured in a similar way—through private-sector insurance companies and plans operating in a regulated marketplace for people without employer-sponsored coverage. That’s why Republicans rarely talk about alternatives to Obamacare in any detail.

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ESCOs: The Value of Disease-Specific Accountable Care

flying cadeuciiPatients with End Stage Renal Disease (ESRD) constitute a high-cost, high-need population that can greatly benefit from targeted policy initiatives to improve care coordination. In 2010, patients with ESRD made up 1.3% of the Medicare population, but accounted for 7.5% of total Medicare spending, amounting to over $20 billion.1 Adoption of the accountable care organization (ACO) model for ESRD has the potential to improve care coordination and patient outcomes. Due to complex health needs, patients in this population can require visits to multiple providers with multiple care plans. By bringing these providers together under the same organizational structure, accountable care provides the opportunity to improve quality through coordination. Though just over 1 million ESRD beneficiaries participated in the Pioneer ACO program, to date no direct studies have examined the effect of ACOs on management of ESRD.

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What Data Won’t Tell you About Caregiving

As I entered CaringBridge through the technology door, the software engineer in me always seeks data to validate the personal experiences of patients, caregivers, family and friends sharing a health journey. So I could hardly wait to dig into the motherlode of facts and figures published in Caregiving in the United States 2015, a major report produced by AARP and the National Alliance for Caregiving.

The numbers were big, with 43.5 million Americans fitting the definition of “caregiver:”

“A person who has provided unpaid care to a relative or friend over the last 12 months that may include helping with personal needs or household chores. It might be managing a person’s finances, arranging for outside services, or visiting regularly to see how they are doing. The person receiving care does not necessarily live with the caregiver.”

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Telehealth is Working in Texas. Here’s Why

Screen Shot 2016-03-23 at 11.14.24 AM

Over the past two years, policy makers across the nation have been actively adopting policies in support of the rapid adoption of telehealth. From states affirming that health insurance plans should appropriately cover care provided through innovative technologies, to Congress contemplating multiple proposals for telehealth expansion within Medicare – telehealth is fast becoming a permanent part of our healthcare ecosystem.

This movement has been most clearly demonstrated by state medical boards. It has been their job to answer the questions: can physicians use technology to extend the reach of their care? Can telehealth be used to create a treatment relationship, and if so, are their limitations to this relationship?

Overwhelmingly, the resounding answer to these questions has been a consistent one – yes, you can use robust telehealth technologies to provide care and the main limitation is simple – uphold the same standard of care. The Federation of State Medical Boards has upheld this concept.

But if you’ve been following this movement, you know there’s a rather large blip on the national map: Texasa state with more than 27 million residents and a clear need for increased access to care – was recently ranked “worst in telehealth” by the National Center for Policy Analysis. The good news: despite restrictive rules and a lawsuit that’s hindering progress, telehealth is working in Texas and changes, they are a coming.

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