By DAVID DRANOVE

I have been thinking lately about the state of the field of health services research. Having plied this trade for nearly 30 years, it struck me that many of the unanswered questions that I encountered as a doctoral student remain unanswered. I plan to post occasional blogs in which I pose these questions, discuss the state of the research, and explain why it is critical that we come up with better answers. The first question is really the big kahuna: If you get what you pay for, how much should you spend?

Everyone seems to agree that the U.S. spends too much money on healthcare. This has led many to embrace machete policies: Slash payments to doctors. Slash payments to hospitals. Slash payments to drug companies. Slash the number of specialists. Slash, slash, slash.

There is abundant research that past machete policies directed towards healthcare providers have adversely affect healthcare quality and access. There is also abundant evidence supporting the view that machete policies would curtail medical innovation. Medical providers and drug companies cite this evidence whenever they are threatened with payment cuts, proclaiming that any reductions from current levels would be disastrous for the American public.

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By PAUL FISCHER, MD

Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much.  It’s part of the same ethic that teaches us not to criticize another doctor’s care.

But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest.  If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?

History shows that physician pay rarely follows value, but rather aligns with power.  When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own.  Power and wealth followed.

About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT and MRI scans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.

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By Matthew Holt

The agenda for the Fall Health 2.0 Conference is up–and it is mega, as in by far the biggest thing we’ve ever done. Just getting the agenda right online took three of us all day!

Four Pre-Conferences. An overnight Code-a-thon and Health 2.0 101, educational session for developers and people new to health care. Two full days of main stage programming including more CEOs and tech whizes than you can imagine. Over 140 live product demos. More than 25 parallel sessions or Deep Dives. Live CEO interviews. And some “Unmentionable” topics never discussed at a health care tech conference before. Not to mention at least 20 brand new product introductions.

The conference is Sept 25-7 in San Francisco. The Exhibit Hall is sold out, the room block is going fast, registration is running well ahead of last year’s record crowd of 1,000, and ticket prices go up on Wednesday. Buy yours now, while they’re still available. Deals will be done, imaginations will be blown, history will be made. You won’t regret coming!

And just in case you need a little taster. From 9.30 PST/12.30 EST I’ll be running a 30 minute tweetchat tweeting from @boltyboy and @health2con. Just follow the #health2con hashtag —this Tweetchat link is a painless way to do that— and have fun with my questions and answers! See you there!

By EVAN FALCHUK

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work help.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study.  According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S.  Some call it the “CSI Effect,” after the TV show, CSI.  In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty.  Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis.  They’re often surprised to see how it really works.  Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis.  Doctors often order high-tech tests because patients expect it.Continue reading…

By ALEX EPSTEIN

He killed the audio CD but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the world wide web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

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By DAVIS LIU, MD

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –

I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.Continue reading…

By EVAN FALCHUK

Conventional wisdom has it that government has lost its way. It’s out of touch and out of control. It has shut out the voices and concerns of everyday Americans. Democracy — or rather, taking the concerns of ordinary Americans into account in the democratic, lawmaking process — is a notion so farfetched as to be laughable.

But what if that weren’t true?

As a private citizen — a native Bostonian with a wife and three kids who seem to think I’m okay, a job I enjoy, and a rabid Red Sox fixation — I set off to see if I could have a say that made a difference.

And here’s the clincher: It actually worked. Really.

Here’s the setup: The state of Florida had in its law a rusty old provision that made it all but impossible for an insurance company that sold insurance abroad from having offices in Florida — even though it would not be selling insurance in the state. That law cost the state untold number of jobs and tax revenue for no apparent reason. Even Florida lawmakers from both sides of the aisle were perplexed as to how and why that initial law had come to be.

This meant American companies like mine that serve the Latin American market were barred from locating in Florida, the gateway to Latin America and home of some of the country’s highest-skilled bilingual workers.

Gov. Rick Scott, I knew from reading the papers, was keen to add jobs for Floridians. So was Insurance Commissioner Kevin McCarty. So was every lawmaker in the Florida Legislature.

So I hopped on a plane (well, lots of planes), knocked on their doors, and made my case. I explained that some simple changes to the old law would create jobs and new revenue for the state — all without spending a dime of government “stimulus.” I worked with staff and legislators on both sides of the aisle — Republican Reps. Bryan Nelson of Apopka, Carlos Lopez-Cantera of Miami, Sen. Garrett Richter of Naples and Democratic Sen. Chris Smith of Fort Lauderdale among them — to create the few brief, sensible improvements, and a few months later, the Legislature included the idea in HB 1087. It took effect this month.Continue reading…