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BLOGS: A great Health Wonk Review

Michael Cannon is hosting Health Wonk Review #21 up at the Cato@Liberty blog. And unlike some HWR hosters (i.e. me) Michael does a great job of not only steering you to the posts, but summarizing them and giving you his views on the legitimacy of the arguments.  And just because he’s wrong most of the time, doesn’t mean that he’s not doing a fabulous job! This is one of the best HWRs yet. (And apparently I’m James Brown!)

And if you’re not reading the Cato blog regularly you’re missing out on among other things a) some of the best argued views from free market advocates on health policy (which I usually disagree with), b) drug policy and human rights (which I’m with all the way), and c) traffic (which will at the least surprise you in a Heinlein fashion, and those ideas comes from those terrible socialists in Europe!)

QUALITY/POLICY/TECH: Quick notes from the road

Apologies to those who’ve missed me. I’ve been lost in the mid-west taking part in some scenario planning about the big picture future of health care. I can’t give you any details (at least not yet) but it did involve me spending lots of time with a bunch of business association lobbyists who’s views on health care, shall we say, the average THCB reader wouldn’t expect me to share.

In the informal conversations, across the board there was, however, one huge topic of agreement amongst the boomers I met. They wanted themselves and their parents to die at home with palliative care; they felt that current end of life care verges not only on the irrational in terms of resource use, but also on the inhumane. And they think that within a decade, we will be having that conversation and forcing that set of opinions onto our medical providers. Who presumably will be rather more willing to hear us out, rather than insisting on engaging in those heroic measures that, the group felt, todays providers feel they must perform.

One other quick thing. Wednesday, Intel, BP and WalMart announced a PHR initiative, which I believe is being largely led by JD Klienke’s group in Oregon. On that topic I’m giving a talk to HIMSS N.California in San Ramon on Tuesday on the topic of PHRs. Also talking will be Kate Christensen from Kaiser Permanente, and Holly Miller from the Cleveland Clinic. I personally think this should be an interesting opportunity to hear a range of views and understand some developments in major PHR deployments from providers (and of course I’ll be witty and brilliant, just as soon as I’ve put my talk together). But apparently according to at least one other blogger, I’ve misunderstood it all, and really I’m just being a PR flack for the devil worshipers at KP central. I’ll report back as to whether the place still smells of sulphur.

 

POLICY: New York Trans Fat Debate Heats Up

The Wall Street Journal reports that McDonalds and other
fast food businesses
are engaged in a last minute drive to convince health
officials in New York City to “soften” the proposed ban on trans fats in restaurants
in the five boroughs. According to the Journal, McLobbyists have approached city council member Peter Vallone and asked him to sponsor a competing measure
that would give the industry more time to make the switch over to healthier
cooking oils. Quoting from WSJ’er Janet Adamy’s piece:

The city’s board of health is scheduled to vote Tuesday on
whether to force city restaurants, from fast-food outlets to servers of haute
cuisine, to eventually remove all but a trace of artery-clogging trans fat from
the food they cook. It’s not certain yet how the board will vote, but people
following the process say the board appears likely to approve the measure.

A New York City ban would place the most significant
restrictions yet on trans fat in the U.S. since health officials began warning
of its dangers years ago. Restaurant chains will feel pressure to more quickly
replace oils in their outlets across the country, since the companies get the
most efficiency and consistency by cooking with a single recipe. Other cities
probably would follow New York.

          — John Irvine

HOSPITALS: Panel Said to Call for Closing 9 New York Hospitals

Somehow I think this will be rather difficult! Panel Said to Call for Closing 9 New York Hospitals

Welcome to the governorship, Mr Spitzer!

UPDATE: Anonymous Coward writes in to say: "The Commission’s proposals actually serve as political cover for the all but certain cuts to Medicaid, and this is actually a good thing for Spitzer.  The closing recommendations have to be approved as a whole (or rejected as a whole, unlikely) before he’s even in office.  Also, dealing with cuts through a more rational, analytical framework, actually enables the new governor to stay completely out of the business of closing hospitals, and to scale back on what otherwise would have been more devastating cuts to Medicaid for all hospitals.  The public relations around this are tricky, but the process is already being closely watched (and followed) in other states."

UPDATE 2: You can read the actual report here. (pdf) Check the New York State Commission for Health Care Facilities in the 21st Century web site for additional materials.

ED’s NOTE: Link fixed to NYT piece.

PHYSICIANS: Pity the poor radiologist

They are “frustrated” by Liability and Lifestyle Issues, only 7% them are truly happy—although 70% would do it all over again if they had the chance (more than most other doctors). And only 25% of them make more than $400K a year and 40% have to struggle by on less than $300K.

But pretty clearly these are the good old days for radiologists. Methinks that if they don’t like it now, the average radiologist may be in for a rude shock in the next decade or two, as technology will make their skills increasingly exportable to other cheaper radiologists abroad and replaceable by computers reading images. Of course, they’ll not be quiet in defending their lucrative turf, and demand for imaging will just keep going up, so their future isn’t quite that of the steel worker in the 1980s.

But this is one place to watch in the coming years.

CONSUMERS/POLICY: Real people really travelling

Via HISTALK, a really interesting column about people traveling to India for surgery. Essentially the total cost slightly exceeds the co-insurance for those with insurance and of course the cost is remarkably lower for the uninsured. The people featured are those in the 50-65 age group who are pre-Medicare and finding it harder and harder to get health insurance are the obvious candidates.

And of course they are the ones for whom the health insurance crisis is biting home, and the ones who will be the swing voters about this issue. I for one cannot believe that this group of Americans will accept that they all need to travel to India and pay out of pocket, over and above whatever catastrophic coverage they are also buying. So when a politician comes up with a believable universal solution, this type of story will be behind what gets it through the Congress.

QUALITY: The herniated disk story

Medpundit has a pretty good explanation of the recent study about herniated disk surgery. Basically it works, but if you wait two years, then the results are about the same as non-surgical treatment—roughly 70% of people get better, and there doesn’t appear to be any long-term harm from delaying surgery. As I have someone very close to me with a current case of extreme back and leg pain from a herniated disk, I’m very interested in the study, and actually more inclined to suggest surgery (especially arthroscopic) sooner rather than later. But in this case the patient, doctor and other advisors are more in favor of waiting it out.

So on a global level it’s more cost-effective not to do the surgery. But on an individual level it probably lessens the pain—and the pain is close to unbearable, and if you have to put up with it for several months, then surgery is probably an option the patient will want.

Note that this is only the case for herniated disks and not lots of the other back issues for which surgery is probably ineffective–but still done at a very high rate.

The good news is that ten years after AHCPR (the forerunner to AHRQ) was decimated by daring to discuss back surgery, we’re getting studies out about this type of issue. Even, as Medpundit points out, it’s not a great study and it’s very, very hard to do studies about this type of intractable medical problem.

CODA: One slightly disquieting anecdote. I asked a local back specialist (non-surgeon) what the best way of doing surgery was (open or athroscopic). He said that the choice depended mostly on the training of the surgeon! Er…shouldn’t the surgeon be trained in the most advanced manner? (I expect those who know to chime in here)

POLICY/POLITICS/PHARMA: PhRMA sends the D out on the field

Even thought the White House will likely veto any change to Part D, the WSJ has started playing desperate defense on behalf of PhRMA.

Apparently if we impose government price controls, it’ll cripple R&D and no new drug will ever be developed. On the other hand, they also trot out the “fact” that Part D as constructed now means that the private sector has the ability to lower prices below those that the government could get. Of course we’ve heard all this before, and we all know who wrote Part D and in whose interests it was written.

But what I wonder is how can the WSJ’s Jane Zhang hold those two contradictory thoughts in her head without smoke coming out of her ears?

Meanwhile, here’s the NY Times on big Pharma’s attempts to buy its way out of the problem. It’ll certainly make some former Democratic staffers much richer!

PHYSICIANS: The New York Times–desperate to fill column inches

When I think about all the problems in American health care, many of them the result of the political and clinical choices made by “older and middle-aged physicians (like myself)” (“Myself” being the author of the piece, Dr Erin Marcus from Miami) I can’t say that the non-formal attire worn by some young doctors  is exactly in the top 5000. In fact wearing a tie, as she (I think Erin is a she) points out, is actually harmful as they collect bacteria—so the chippie with the low cut top is better for the patient than the stuffy old doc wearing the tie!

But honestly, has the paper of record got nothing better to say about physicians, and no one more interesting than Dr. Marcus to invite to write about them? I’m reminded of open sores…..

Happy Thanksgiving!

TECH/HEALTH PLANS/QUALITY: Lonny Reisman, Active Health Management transcript

Here’s the transcript from the podcast I did with Lonny Reisman, a week or so back. Really interesting stuff for those of you interested in the future of patient care management.

Matthew Holt: So welcome to another forecast here at The Health Care Blog. I’m Matthew Holt, and today very exciting that we’re talking with somebody’s who’s really been a technology pioneer and a medical pioneer in developing tools for active health management, and surprising enough, his company is called Active Health Management and I’m talking with Lonny Reisman. Lonny, how are you today?

Lonny Reisman: I’m well, thank you. How are you?

Matthew: We’re doing pretty well over here. One of the first fall and somewhat foggy days in San Francisco, but at least we’re not going to endure that terrible New York winter you’re going to have to go through [laughter]. Anyway, let me very briefly give a sense to, in essence, what your organization does. And there are a couple of things that people who may or may not necessarily have heard of Active Health Management should know. First off is that you are in the business of taking data, all kinds of different data about medical information about patients, putting it all together and spitting it back out and using it to try and help and inform and change medical decisions by those patients and physicians. And the second one is that you’ve been so successful at that, that last year, Aetna decided to write a very big check, $400 million to buy you, and now you’re part of that large insurance company. So with that it’s a very brief introduction. why don’t you say a little bit about what Active Health Management does, how you got started, and what kind of impact you’ve been having in the healthcare system and the part of it you’re specializing in.

Lonny: Sure. Why don’t I start with my background, which will give you a sense of how we have come to be here. I’m board-certified in internal medicine in cardiology, I’m a physician, and during the 1990s I was leading a bit of a dual existence. I was practicing clinical medicine here in New York City, had a fairly typical practice, but I also was consulting with a large human resources consulting firm, William M Mercer, and was charged with evaluating health plans around the United States, mostly from my perspective on the basis of quality but obviously the premiums and the costs associated for those health plans was a consideration as well. In considering what I was experiencing as a practitioner and what I saw as a consultant evaluating health plans, saw an opportunity to better take advantage of clinical data that were available in the managed care world which weren’t being fully exploited. So specifically as I visited health plans I saw that they had the capacity to collect drug information, laboratory results, information about procedures and diagnoses and basically had the thought that if in fact that information could be used to support doctors and patients in making decisions, that in fact we’d be able to raise the bar with regard to the level of clinical excellence being provided to patients all over the United States. So fundamentally, the observation that I made, which ended up being relevant to what I was experiencing as a practitioner was that to the extend that the care that was being provided by me and others was fragmented, specifically I didn’t necessarily know what other doctors were doing to my patients or for my patients, to the extent that all of the information about a patient or much of it could be aggregated at the health plan level, we decided to take advantage of that.

The other component of Active Health, which again sort of derives from my own experience and perhaps insecurity, is that I recognized early on in my career that it’s very, very difficult to keep up. So there are thousands of articles, relevant articles, published yearly and the issue is how does one not only read and assimilate and remember those articles, but how does a physician relate the information in an article that they’ve read to the particulars that relate to a patient sitting in front of that doctor during the course of an office visit.

Matthew: They can’t is basically the answer, correct?

Lonny: Can’t do it, right, exactly. It’s just too much. So the basic notion and this is as true today as it was in 1998 when we started the company was if in fact you could provide the treating physician with more clinical data on the member than they have access to—again the patients frequently see multiple doctors—and then if you could expose those data to thousands of clinical rules that represent incontrovertible standards of clinical excellence and use technology to highlight discrepancies between what was actually happening to the patient as manifested in their data as opposed to what should be happening as displayed in the literature, we in fact could pinpoint changes that needed to be applied to individual patients by doctors that related to everything from preventive care to diagnostic services to therapeutics to follow-up, and basically started the company with the notion that we would have those data, have a technology that would analyze those data and communicate first with doctors and then over the years with patients in order to again introduce this level of consistency to the healthcare system. And from there we’ve evolved into other sort of disease management like capabilities which I’ll elaborate on. But the fundamental premise behind the company is what I’ve articulated.

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