In this Episode of #healthin2pt00 Jess & I do a real recap of the Health 2.0 Conference. I mention some of the startups that I thought were great, including Supportiv, Tag.bio, Nebula Genomics, Bluestream Health, Medically Home, b.well, and Medsafe. I also want to highlight Krista from Project HEAL that started an organization to raise awareness about mental health & eating disorders. We also discuss #CMS and Ro receiving $88 million in its funding round- Matthew Holt
By MATTHEW HOLT
So The Health Care Blog (which I like to think of as the first proper health care blog whatever Jacob Reider says about his Docnotes which started in 1999!) is 15 yrs old this month. This is the start of our little anniversary celebration. We are going to be running some of the earlier classic posts. The very first post on “What’s wrong with Medicare” still rings true- Matthew Holt
For the first post, don’t expect a big essay despite that subject line. It came up because while I was away from the US for the first part of this year, yet another incarnation of NME or HCA — the two original for profit hospital chains of the 1970s that amalgamated into Columbia (now calling itself HCA again!) and Tenet — got caught with its hand in the cookie jar. You’ll remember NME getting bad press and worse in the 1980s for imposing unwanted inpatient stays on “psychiatric patients”. After that NME morphed into Tenet. Columbia of course said that “health care had never worked like this before” and they were right — to the extent of the upcoding and fraudulent billing going on in its hospitals in the mid 1990s. I remember one cover of Modern Healthcare in which Tenet’s strategy was encapsulated as “We’re not Columbia”. Apparently only slogan deep. Last week they settled with the state and feds in California due to massive amounts of upcoding and worse at Redding Medical Center. Several other settlements are pending.
The New York Times’ description (registration req’d) of the level of unnecessary surgery at the Redding Medical Center is quite shocking. But I do recall Alain Enthoven at Stanford telling me in 1991 that one third of carotid andarterectomies in California were found to be counter-indicated after chart review. Why were they done? Well everyone — surgeons, hospitals, supplier– made money by doing them. Given the imbalance in knowledge between a patient and a doctor, it’s not too surprising that a very aggressive surgeon can do way more than he or she should. Medicare is still basically a fee-for-service program with very little oversight, and so this type of thing is going to go on and on. And it has been going on for a while, as this partial list of whistlebower suits shows. Enthoven’s view was that everyone should be put into competing managed care plans which would act as patient (and payer) sponsors, and look after the money better than the government could. It didn’t happen that way, and the backlash against managed care’s ham-fisted attempts to do so ensured that most health plans gave up on trying to control what providers did. Medicare never really ever tried, as all its internal review cases were co-opted by providers. Its only weapons were inquisitions and indictments from the FBI and others well after the fact. Eventually Medicare will have to have more controls, but that will need reform as well as more money. I’ll talk more about this when I get to drug coverage later this week. Suffice it to say, don’t hold your breath.
Meanwhile, Uwe Reinhardt says in the NY Times article that (despite Wall Street’s desires) hospitals “can’t be a growth industry like some Internet company”. Well maybe not a “growth” sector, Uwe, but look at Yahoo’s stock price in 2000, Tenet’s this year, and tell me that you’re not getting some of that Internet fever coming back!
Matthew Holt is the Founder of THCB.
How are teens and young adults engaging with digital health? Results of a national survey asking just that were released today by Susannah Fox (Former CTO at US Dept of HHS) and her research partner, Victoria Rideout.
You can check out the full report of the findings here, but I spoke with Susannah in April, just as she and Victoria were starting to draw some insights from their work.
Hearing her talk about the survey at this stage of synthesis is not only unique (most researchers won’t talk until the findings are published) but more so because it adds a layer of understanding to the final results now that they’re here.
We get her candor about how teens and young adults are a wildly viable – yet very overlooked – market for digital health…
We see how she’s trying to formulate a much larger hypothesis about what healthcare can learn about social media from a generation that has never lived without it and, more importantly, view it as having a positive impact on their well-being…
And, probably most inspiring to me, we see an approach to health data that stands out for its warmth. For it’s love, really. In a world of big data and clinical trials, it’s endearing to hear from someone who is taking a more anthropological approach and who has fallen absolutely, head-over-heels in LOVE with the personal side of her dataset.
As we all clamor for a patient-centered end, we’d be remiss to underestimate the value of a human-centered starting point. Watch Susannah Fox for a strong model of how this can be done in health research.
Filmed at Health DataPalooza, Washington DC, April 2018. Find more interviews with the people pushing healthcare to better tomorrow at www.wtf.health.
By SAURABH JHA
I’ve humbly realized that doctors aren’t always indispensable. When I was three, a compounder – a doctor’s assistant – allegedly saved my life. Dehydrated from severe dysentery, I was ashen and lifeless. My blood pressure was falling and I would soon lose my pulse. I needed fluids urgently. An experienced pediatrician could not get a line into my collapsed veins. When hope seemed lost, his compounder gingerly offered to try, and got fluids inside my veins on the first attempt. My pulse and color returned and I lived to hear the tale from my mother.
So, on a recent trip to India, I was intrigued by Birju, a compounder in my ancestral village in Bihar, who the villagers revere like a doctor. After assisting a city physician for ten years, Birju had started his own practice. He has no formal training in healthcare. Even his education was partial – he left school at fourteen to help his father, who also was a compounder.
I wanted to see Birju practice his craft. So, I visited his clinic which is actually a shop. Birju sells stationery, conveniences such as shaving foam, and medications, which was just as well, as I needed Imodium to calm my angry Americanized bowel.
OK, so it’s a tad of an ambitious title… but it was a talk that I gave in Finland last month. I had fun looking at the development of health and technology and suggesting a structure for the future. Plus I got to tell my Neil Armstrong joke. The talk was part of the Upgraded Life Festival in Helsinki and you can see some of the other speakers videos on their channel—Matthew Holt
WTF Health – ‘What’s the Future’ Health? is a new interview series about the future of the health industry and how we love to hate WTF is wrong with it right now. Can’t get enough? Check out more interviews at www.wtf.health.
How can patients help usher in a better future for healthcare? Start speaking up. LOUDLY.
In this WTF Health interview, meet one of health’s most outspoken patient advocates, Twitter voices (@mightycasey) and podcasters, Casey Quinlan of Mighty Casey Media, who talks about her patient journey as a cancer survivor — and why the awful experience led her to tattoo a QR code linking to her electronic medical record to her chest.
Casey’s ‘physical political protest’ is tied to her passionate views about the lack of data liquidity in healthcare and how patients suffer as a result. She’s launching a new “If-You’re-Selling-My-Health-Data-Cut-Me-In” Movement and weighs in on why more patients aren’t clamoring after their health data to push real change in the healthcare system.
Filmed at Health Datapalooza in Washington DC, April 2018.
By, SAURABH JHA MD
In the ongoing battle between radiologists and artificial intelligence, is the real risk not that computers will replace radiologists, but that radiologists will become machines? This lecture delivered at the annual meeting of the ARRS explores the evolution of radiologists, from inference to quantification, and what it means for the field.
By ANISH KOKA
Physicians have been making up numbers longer than people have been guessing weights at carnivals. How much does this statin lower the chances of a heart attack? How long do I have to live if I don’t get the aortic valve surgery?
In clinics across the land confident answers emerge from doctors in white coats. Most of the answers are guesses based on whatever evidence about the matter exists applied to the patient sitting in the room. The trouble is that the evidence base used to be the provenance of experts and anecdotes that have in the past concluded leeches were good for pneumonia.
And so came the randomized control trial to separate doctors from homeopaths. Random assignment seeks to achieve balance between two groups for everything but the treating variable to isolate the effect of the treatment. But does randomization really guarantee a balance between groups? At least the known confounders may be measured in the two groups, but what about unknown confounders?Continue reading…
By ANISH KOKA
The phone rings. It’s not supposed to be ringing. It’s 2 am. The voice on the other line is from an apologetic surgery resident.
Resident: There is this patient..
Me: Yes, go ahead. Please.
Resident: He’s tachycardic.
Me: How fast?
Resident: 160 ?
Me: What’s the blood pressure?
Resident: An SVT I think.. I gave adenosine. Nothing happened
Me: Audibly groaning. I’ll be in..
Forty five minutes later I’m at the bedside of a decidedly ill appearing man.
I want to be triumphant that his heart rate is only 145, and a quick glance at the telemetry monitor above his bed uncovers juicy p waves in a cadence that suggests this is no primary electrical arrhythmia.
Something is very wrong somewhere – the heart in this case is an innocent bystander being whipped into a frenzy to compensate for something.
At the moment the whip is a norepinephrine infusion being used to keep his blood pressure up.
I ask the nurse if the amount of norepinephrine infusing has been stable. She replies that his dose has been slowly escalating.
Eureka! I think – the heart rate response in this case is being driven by the norepinephrine – a powerful adrenaline that acts on beta receptors and alpha receptors within the body that increase heart rate and constrict the blood vessels to raise blood pressure. Fix the cause of the low blood pressure, come down on the norepinephrine, and perhaps the heart rate would be better.
But it turns out this particular post surgical patient doesn’t have a medical cause of low blood pressure I can find. I cycle through cardiac ultrasounds, blood gases, steroid and volume challenges, and try inching down on the norepinephrine.
All of it is to no avail. I’m growing more and more convinced this problem is surgical in nature. Perhaps an infarcted piece of bowel? All I know is that the man acts like he has no peripheral vascular tone.
An interesting thing happens shortly after. The norepinephrine drip runs out.
As one nurse runs to get another bag from the pharmacy – a quick cascade of events unfolds.
The brisk upstroke from the arterial line that marks the pressure wave generated with every beat of the heart starts to dampen. The color seems to visibly drain from the patients face, and he begins to complain that his vision is getting blurry. His systolic blood pressure is 70 – an almost forty point drop within a minute of the norepinephrine running out.
By ANISH KOKA
The weekend started with a tweet about an elderly man with atrial fibrillation. Atrial fibrillation is an arrhythmia of the heart that predisposes those who suffer with it to strokes. The strokes are a result of clots being thrown from the heart into the brain. The typical treatment for this condition in those deemed high enough risk is to thin the blood to help prevent these clots from forming, and thus reducing the risk of stroke.
101 year old with a history of a stroke stops his Pradaxa. Only other history hypertension. https://t.co/Ai5z519rcX— Anish Koka (@anish_koka) June 3, 2018
The problem with thinning the blood is that the risk of bleeding increases, and it does so especially as one advances in age. It doesn’t help matters that the risk of having a stroke also increases with age.
In a 101 year old deciding on the best course of action is thus a challenging one. It is easiest when patients are adamant about a certain path. Far be it from me to tell a centenarian what to do. In this case, the man who had been alive for two world wars chose to come off the anticoagulant he had been dutifully prescribed.
I queried the audience
Most leaned towards stopping Pradaxa, and some responded that there wasn’t a wrong answer.