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Category: Health Policy

How About This Opportunity, Health Tech Investors? Promoting Contraception vs. Banning Abortion

By MIKE MAGEE

Dr. Linda Rosenstock has an M.D. and M.P.H. from Johns Hopkins, and was a Robert Wood Johnson Clinical Scholar. She is currently Dean Emeritus and Professor of Health Policy and Management at UCLA’s Fielding School of Public Health, but also spent years in government, and was on President Obama’s Advisory Group on Prevention, Health Promotion and Integrative and Public Health.

In the wake of the release of Justice Alito’s memo trashing Roe v. Wade, she was asked to comment about the status of abortion in America. Here is what she said:

The broader the access to proven family planning methods, the lower the unintended pregnancy rate and the lower the abortion rate. We cant underestimate the role of educating and empowering women – and men – about these issues.”

These are not simply the opinions or insights of a single health expert. They are backed up by the following facts:

  1. Since 1981, abortion rates in U.S. women, age 15 to 44, have declined by nearly two thirds from 29.3 per 1000 to 11.4 per 1000.

2. Approximately half of all pregnancies in the U.S. are unintended.  Of those unintended, approximately 40% of the women chose to terminate the pregnancy by abortion – either procedural or chemically induced.

3.  The decline in the number of abortions has coincided with increased access to long-acting reversible contraception, including IUD’s and contraceptive implants. These options are now safe, increasingly covered by insurers, and more accessible to at-risk populations.

4. The increasing inclusion of sex education in middle school and high school curricula has been accompanied by a decline in high school sexual activity by 17% between 2009 and 2019.

5. There were 629,898 abortions recorded by the CDC in 2019. For every 1000 live births that year, there were 195 other women who chose to terminate their pregnancies. Almost half of the 1st trimester abortions are now chemically induced through Plan B-type pills.

What is clear from these figures is that knowledge and access to contraception is the best way to decrease the number of abortions in America.

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The Licensing Walls Come Tumbling Down

BY KIM BELLARD

Abortion rights continue to be one of the most heated issues in American politics, super-fueled by last week’s leak of a draft Supreme Court opinion that would overturn 1973’s Roe v. Wade and return the issue to the states to decide. 

I’ll leave it to others more qualified than me – women, for example — to weigh in on abortion itself, but I want to talk about how abortion pills are going to force changes to our healthcare system that many may not be ready for.

Although the stereotype of abortions is a procedure done by a physician in an office/clinic, the majority of abortions in the U.S. are now done through the use of abortion pills.  It is a two step process, and the two medications must be prescribed by a physician. Until last December, women were required to see a physician in person, but the FDA permanently lifted those requirements, following a temporary waiver during the pandemic. The pills are considered both highly effective and safe.  There are startups, like Hey Jane and Just the Pill, that specialize in them.

Not surprisingly, since the leak searches for “abortion pills” have hit all-time highs.

The states that have been passing various abortion bans have not ignored the loophole that abortion pills represent. There are a variety of restrictions that have been enacted, such as requiring in-person visits to outright banning use of telehealth for them. In those states, some women have opted to travel out of state to do the telehealth visit and/or to receive the pills via the mail. 

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Learning from This War

BY KIM BELLARD

There’s an old military adage that generals are always fighting the last war.  It’s not that they haven’t learned any lessons, it’s more than they learned the wrong lessons.  I fear we’re doing that with the COVID pandemic.  

The next big health crisis may not come from another COVID variant; it may not be caused by coronavirus at all.  Even if we learn lessons from this pandemic, those may not be lessons that will apply to the next big health crisis.  

What started me thinking about this is a C4ISRNET interview with Mike Brown, the Director of the Defense Innovation Unit, and DARPA Director Dr. Stefanie Tompkins.  Dr. Tompkins and Mr. Brown are both watching the war in the Ukraine closely.  As Dr. Tompkins says in the interview, the war is a “really good test” about the programs her agency has invested in and/or is investing in for the future.

E.g., Russia has clear advantages in numerical superiority, and in “traditional” weapons like tanks, airplanes, ships, and artillery, but Ukraine has been able to blunt the invasion through asymmetrical warfare, using things that DARPA helped foster, including Javelin missiles, drones, satellite imagery, secure communications, and GPS.  Even Russia’s vaunted cyber capabilities have been overmatched by Ukraine’s own capabilities.  Current DARPA investments like hypersonic missiles and AI are being tested.

I’m comforted that DARPA and DIU are learning in real time what lessons their agencies can learn to help fight future wars, but I’m wondering who in our healthcare system, and who in our governments (federal/state/local), are not just fighting COVID but learning the bigger lessons from it to fight future crises.  

I trust that smarter people than me are looking at this, but here are some the lessons I hope we’ve learned:

Information: it’s shocking, but we don’t really know how many people have had COVID.  We don’t really know how many have it now.  We like to think we know how many have been hospitalized and how many have died, but due to reporting inconsistencies those numbers are, at best, approximations.  

We need early warning systems, like through wastewater monitoring.  We need standardized public health reporting, with real-time data and a central repository in which it can be analyzed.  We need easy-to-understand dashboards that both public officials and the public can access and base their decisions on.  We can’t be building these during a health crisis.

Supply Chains: just-in-time, globally distributed supply chains are a marvel of modern life, bringing us greater variety of products at more affordable prices, but, in retrospect, we should have understood that in a global health crisis they would prove to be an Achilles heel.  Masks and other PPE, ventilators, vaccines and other prescription drugs have all suffered from supply chain issues during the pandemic.  Shortages led to unevenly distributed supplies and higher prices.  

We’re never going back to the days of local production, but we do need to prioritize what things need to be produced regionally/nationally, how that production can scale in time of crisis, and how that production should be fairly allocated.  The mechanisms to do that can’t be built on the fly.

The sick and the dead: Among the many images of the pandemic’s worst (so far) days, some of the most haunting are the ones of hospitals filled to overflowing, with patients on gurneys in hallways, or the refrigerator trucks filled with dead bodies.  Our healthcare system’s capabilities for both were simply overwhelmed – as was the healthcare workforce.

Hospital beds are expensive to build, and expensive to maintain.  We can’t afford a healthcare system that builds them for the worst case scenario.  But we can learn from innovative efforts during the pandemic, like building temporary hospitals that can be expanded or contracted as needed.  

Similarly, there has to be a strategy for dealing with dead bodies during a global health crisis, especially one in which those bodies themselves may carry ongoing risks.  Existing morgues, mortuaries, and even graveyards may not be sufficient.  There needs to be a plan.

Hardest to solve are healthcare workforce shortages.  It’s not easy to train new healthcare workers, and retaining them when they’re stressed beyond belief proved to be a challenge.  In a crisis, we need them all working at the top of the licenses, able to cross workplaces and even state lines, and properly supplied and compensated.  None of those is a “normal” state of affairs for our healthcare system, and all are inexcusable in a crisis.

Telehealth: telehealth seemed to finally gets its day during the pandemic, with relaxed regulation, improved reimbursement, provider adoption, and consumer preference.  It took pandemic to make us realize that making sick, potentially contagious, patients travel to get care is not a good idea.

That being said, now that the pandemic is in a more manageable phase, the bloom seems to be off the telehealth rose, with regulations being reapplied, providers not fully incorporating into their practice patterns, and patients returning to in-person visits.

Hey: it’s 2022.  We have the technology to do telehealth “right.”  Aside from, say, a heart attack or an auto accident, telehealth should always our first course of action.  Our licensing, our reimbursements, and our work flows need to facilitate this – not just to prepare for the next health crisis, but simply as part of a 21st century healthcare system. 

Communication: One of the most unexpected results of the pandemic is the distrust of public heath advice – vilifying public health officials, spurning mitigation efforts like masking or isolation, and spurring on the already-present anti-vaxx movement.  “Science” is seen as in the eye of the beholder. It’s an information war, and health is losing.

We need the tools to fight the health information war more effectively. We need to learn how to communicate more effectively.  We need to reestablish faith in science.  We need responses to a health care crisis to be a health issue, not a political one.  

————

We will be taken by surprise by the next health crisis.  We had plans for a pandemic, but, when it hit, we fumbled every response.  Next time we’ll be expecting another COVID, and, if it’s not, we’ll be caught flat-footed again.  

The current crisis is, to use Dr. Tompkins’ words, a really good test for whether we’re working on the right things for our next health crisis.  I’m not so sure we are.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

ONC Explainer: Micky Tripathi Deep-Dive on Info Blocking, API standardization & TEFCA

By JESS DaMASSA, WTF HEALTH

Micky Tripathi the National Coordinator for Health Information Technology at HHS says this year will be a “transformative” year for Health IT as the decade-long, $40 billion dollar effort to lay an electronic foundation for healthcare delivery heads to the next level. Why is this year THE YEAR when it comes to the digital exchange of health information? Where is federal health IT strategy headed in order to provide the standards and policies health tech co’s need to be able to kick up the pace of innovation?

We get into a SWEEPING chat about the technology and business implications of all the work coming out of ONC, including implementation of those new information blocking regulations, goals for API standardization, and TEFCA (Trusted Exchange Framework & Common Agreement). Micky not only gives the background on the regulations and policies, but also provides some analysis on what they actually mean for those health technology companies trying to do business in-and-around a more digital healthcare ecosystem.

Healthcare Suffers from Patient Bias

By KIM BELLARD

If you went to business school, or perhaps did graduate work in statistics, you may have heard of survivor bias (AKA, survivorship bias or survival bias).  To grossly simplify, we know about the things that we know about, the things that survived long enough for us to learn from.  Failures tend to be ignored — if we are even aware of them. 

This, of course, makes me think of healthcare.  Not so much about the patients who survive versus those who do not, but about the people who come to the healthcare system to be patients versus those who don’t. It has a “patient bias.”

Survivor bias has a great origin story, even if it may not be entirely true and probably gives too much credit to one person.  It goes back to World War II, to mathematician Abraham Wald, who was working in a high-powered classified program called the Statistical Research Group (SRG).

One of the hard questions SRG was asked was how best to armor airplanes.  It’s a trade-off: the more armor, the better the protection against anti-aircraft weapons, but the more armor, slower the plane and the fewer bombs it can carry. They had reams of data about bullet holes in returning airplanes, so they (thought they) knew which parts of the airplanes were the most vulnerable.

Dr. Wald’s great insight was, wait — what about all the planes that aren’t returning?  The ones whose data we’re looking at are the ones that survived long enough to make it back.  The real question was: where are the “missing holes”?  E.g., what was the data from the planes that did not return?

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Dara’s “Hero Quest”: How About Embracing Universal Health Care in America?

By MIKE MAGEE

Joseph Campbell, who died in 1987 at the age 83, was a professor of literature and comparative mythology at Sarah Lawrence College. His famous 1949 book, “The Hero With a Thousand Faces” made the case that, despite varying cultures and religions, the hero’s story of departure, initiation, and return, is remarkably consistent and defines “the hero’s quest.” Bottom line: Refusing the call is a bad idea.

George Lucas was a close friend and has said that Star Wars was largely influenced by Campbell’s scholarship. On June 21, 1988, Bill Moyers interviewed Campbell and began with a clip from Star Wars where Darth Vader says to Luke, “Join me, and I will complete your training.” And Luke replies, “I’ll never join you!” Darth Vader then laments, “If you only knew the power of the dark side.”

Asked to comment, Campbell said, “He (Darth Vader) isn’t thinking, or living in terms of humanity, he’s living in terms of a system. And this is the threat to our lives; we all face it, we all operate in our society in relation to a system. Now, is the system going to eat you up and relieve you of your humanity, or are you going to be able to use the system to human purposes.”

Systems gone awry? Think Putinesque Russia, or Psycho-pernicious Trumpism, or Ultra-predatory Capitalism.

Dara Kharowshaki, the CEO at Uber, who took over the company from uber-bro, Travis Kalanick, is a fan of Campbell’s and understands the journey of a hero – departure, initiation, return. Perhaps that is why he defines “movement” as fundamental to life…adding deliberately the qualifier “movement in the right direction.” In an interview in December, 2021, with Brian Nowak, Equity Analyst, U.S. Internet Industry, for Morgan Stanley, he pushed for corporate engagement in a range of issues including “sustainability, safety, equity, and anti-racism – these are all issues that go to the core of who we are, and our identity.”

How did health care escape that list, especially considering the companies investment in “Uber Health” – a health care delivery service promoting speed, care coordination, privacy, and cost-effective and reliable transport to and from care-giving brick and mortar?

It may have something to do with the fact that Uber has fought tooth and nail to avoid providing health care as a benefit to its drivers. In 2020, the company joined Lyft, DoorDash and other gig companies in throwing $205 million into a lobbying effort in California titled “Yes on 22”.

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We Love Innovation. Don’t We?

BY KIM BELLARD

America loves innovation.  We prize creativity.  We honor inventors.  We are the nation of Thomas Edison, Henry Ford, Jonas Salk, Steve Jobs, and Stephen Spielberg, to name a few luminaries. Silicon Valley is the center of the tech world, Hollywood sets the cultural tone for the world, and Wall Street is preeminent in the financial world. Our intellectual property protection for all that innovation is the envy of the world. 

But, as it turns out, maybe not so much. If there’s any doubt, just look at our healthcare system.  

———

Matt Richtel writes in The New York TimesWe Have a Creativity Problem.”  He reports on research from Katz, et. alia that analyzes not just what we say about creative people, but our implicit impressions and biases about them.  Long story short, we may say people are creative but that doesn’t mean we like them or would want to hire them, and how creative we think they depend on what they are creative about.  

“People actually have strong associations between the concept of creativity and other negative associations like vomit and poison,” Jack Goncalo, a business professor at the University of Illinois at Urbana-Champaign and the lead author on the new study, told Mr. Richtel. 

Vomit and poison?  

A previous (2012) study by the same team focused on why we say we value creativity but often reject creative ideas.  “We have an implicit belief the status quo is safe,” Jennifer Mueller, a professor at the University of San Diego and a lead author on the 2012 paper, told Mr. Richtel.  “Novel ideas have almost no upside for a middle manager — almost none, The goal of a middle manager is meeting metrics of an existing paradigm.” 

You’ve been there.  You’ve seen that.  You’ve probably blocked a few creative ideas yourself. 

The 2012 research pointed out: “Our findings imply a deep irony.  Prior research shows that uncertainty spurs the search for and generation of creative ideas, yet our findings reveal that uncertainty also makes us less able to recognize creativity, perhaps when we need it most.  Moreover, “people may be reluctant to admit that they do not want creativity; hence, the bias against creativity may be particularly slippery to diagnose.”

In the new study, participants were given two identical descriptions of a potential job candidate, except that one of the candidates had demonstrated creativity in designing running shoes, but the other in designing sex toys (the researchers note: “the pornography industry plays a significant role in the refinement, commercialization, and broad dissemination of innovative new technologies”).  The participants explicitly rated the latter candidate as less creative, although their implicit ratings showed equal ratings.  

The researchers concluded:

Collectively, the findings strongly support our contention that implicit impressions of creativity can readily form, be differentiated from a traditional explicit measure, and uniquely predict downstream judgment, such as hiring decisions, that might be relevant in an organizational context.

This matters, they say, because: “the findings of study 4 seem to square with real world examples of highly creative people who were ignored until well after their death because their work was too controversial in its time to be recognized as a creative contribution…”

Umm, anyone remember Ignaz Semmelweis?

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Ukraine’s Secret Weapon – “Moral Superiority”

BY MIKE MAGEE

Two hundred and ten years ago, on September 7, 1812, a Putinesque commander, narrowly won a battle, but lost a war and entered a downward cycle that ended his reign. The battle was the Battle of Borodino, a town on the river Moskva, 70 miles west of Moscow. The commander was Napoleon.

The facts are clear-cut: Napoleon arrived with 130,000 troops, including his 20,000 Imperial Guards, and 500 guns. Opposing him were 120,000 Russians with 600 guns. The battle engaged from 6 AM to Noon. The French took 30,000 casualties, while the Russians lost 45,000 men, but survived to fight another day.

As Leo Tolstoy describes the scene of carnage on page 818 of his epic novel, War and Peace, in 1867“Several tens of thousands of men lay dead in various positions and uniforms in the fields and meadows where for hundreds of years peasants of the villages…had at the same time gathered crops and pastured cattle. At the dressing stations, the grass and soil were soaked with blood over the space of three acres. Crowds of wounded and unwounded men of various units, with frightened faces, trudged on…Over the whole field, once so gaily beautiful with its gleaming bayonets and puffs of smoke in the morning sun, there now hung the murk of dampness and smoke and the strangely acidic smell of saltpeter and blood. Small clouds gathered and began to sprinkle on the dead…”

But in the next paragraphs, it becomes clear that Tolstoy’s intent and focus is not to describe why and how Napoleon had won the Battle of Borodino, but rather how this was the beginning of the end of his army and the Napoleonic reign.

Tolstoy writes: “For the French, with the memory of the previous fifteen years of victories, with their confidence in Napoleon’s invincibility, with the awareness that they had taken part of the battlefield, that they had lost only a quarter of their men, and that they still had the intact twenty-thousand-man guard, it would have been easy to make the effort (to advance and annihilate the Russians)….But the French did not make that effort….It is not that Napoleon did not send in his guard because he did not want to, but that it could not be done. All the generals, officers, and soldiers of the French army knew that it could not be done, because the army’s fallen spirits did not allow it….(They were) experiencing the same feeling of terror before an enemy, which, having lost half his army, stood as formidably at the end as at the beginning of the battle. The moral strength of the attacking French was exhausted…(For the Russians, it was) a moral victory, the sort that convinces the adversary of the moral superiority of his enemy and of his own impotence, that was gained by the Russians at Borodino.”

The Russians not only retreated, but did not stop in Moscow, continuing another 80 miles beyond their beloved city. But as Tolstoy describes, “In the Russian army, as it retreats, the spirit of hostility towards the enemy flares up more and more; as it falls back, it concentrates and increases.” 

As for the French, they take Moscow but stop there. Again from Tolstoy, “During the five weeks after that, there is not a single battle. The French do not move. Like a mortally wounded beast, which, losing blood, licks its wounds, they remain in Moscow for five weeks without undertaking anything, and suddenly, with no cause, flee back…without entering a single serious battle…”

Putin’s aging dreams of conquest likely are Napoleonic in scale. But as his hesitant forces observe the Borodino-like human carnage that they have unleashed on Mariupol, at the estuary of the Kalmius and Kalchik rivers, and prepare to enter Kyiv, the first eastern Slavic state which, a Millennium ago, acquired the title “Mother of Rus Cities”, their vulnerability and lack of “moral strength” is already apparent. Lacking a rational stated goal other than dominance, the young Russian conscripted soldiers and their commanders must certainly grow more concerned day by day.  They too have become entrapped, and are “experiencing the same feeling of terror before an enemy, which, having lost half his army, stood as formidably at the end as at the beginning of the battle.” 

As for Putin, like Napoleon, he may feel the winds of fate blowing heavily on his shoulders even now. Napoleon did make it back to Paris. But three years after the Battle of Borodino and the 5-week occupation of Moscow, he met his Waterloo on June 16, 1815, at the hands of the Duke of Wellington.  He died in exile on the island of Helena on May 5, 1821. In his last will, he wrote, “I wish my ashes to rest on the banks of the Seine, in the midst of that French people which I have loved so much.”

Putin likely feels a similar love for Mother Russia, but ultimately the Russian people may choose not to return the affection.

Mike Magee, MD is a Medical Historian and Health Economist, and author of  “CodeBlue: Inside the Medical Industrial Complex.“

MedPAC Got It Wrong (pt 3)

By GEORGE HALVORSON

This is the third part of former Kaiser Permanente CEO George Halvorson’s critique of Medpac’s new analysis of Medicare Advantage. Part 1 is here. Part 2 is here. Eventually I’ll be doing a summary article about all the back and forth about what Medicare Advantage really costs!-Matthew Holt

Risk status and RAF

What is on the MedPac radar screen and what keeps their attention and what actually takes up several long portions of the annual report this year is the other factor that changes the payment levels to the plans — the risk status of their enrollees.

The capitation levels that are paid to the plans are affected very directly by the health status levels of the actual enrollees.

Risk levels for the members set and change the payment levels for the plans. The very first capitation programs didn’t factor in relative risk status for the members, and it was possible for some care sites to make major profits on capitation just by enrolling healthier than average people and by being paid an average cost level for each area for the people they enrolled.

That initial payment process has evolved very intentionally into having diagnosis-based cost factors that attempt to link the health status of the members and a fair payment level for the plans. The plans identify for the risk filing process the diagnosis levels for the members and their payment levels as plans are directly affected by the risk levels they report for their members.

People have had some concern about whether some parts of that coding process have been done badly, incorrectly or with purely avaricious intent.

There have been significant levels of concern expressed about whether the plans might be able and willing to produce and present inaccurate and distorted information in the process. That alarm was triggered in part by the fact that some of the plans made getting that information into their annual filings a high priority and some were more successful than others in that process.

It is good to have accurate diagnosis information.

We actually should as a nation and a health care macro system want to see an expansion of our data base and our medical records on basic levels of diagnostic information.

As a nation and as a macro care system we should definitely want to have full diagnosis information for each patient. Care can be better when caregivers have the right diagnosis for all of their patients.

How CMS  has changed Risk Adjustment

CMS just did a brilliant thing and completely eliminated the filing system and process for risk coding and data.

The CMS Hierarchical Conditions Categories Risk Adjustment Model was just killed. CMS just took the system that has created the vast majority of concerns and churn about the issues of coding intensity and shut it down.

It no longer is a factor for any risk scores. CMS will still look at the relative risk levels of patients but will get that information completely from patient encounter filings and direct patient information and not from any plan filings or reports.

An entire industry of organizations working to enhance risk scores just became obsolete and irrelevant.

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988 and 911: Justice System Involvement in Mental Health Crises

BY BEN WHEATLEY

A woman was walking in the crosswalk of a busy intersection as the rain started to come down. She looked cold, but more than that, she looked off. She had no shoes on her feet and her countenance was in disarray. It seemed to me that she was in the midst of a mental health crisis. 

The woman approached where I was standing and I suggested that she go into the Starbucks on the corner to look for her shoes. At least in there, it would be warm. She didn’t go inside, but instead went to the entrance and sat down on the ground. 

Someone must have called 911 because a policeman and an ambulance with an emergency medical technician showed up. The EMT brought a stretcher down from the ambulance as the policeman watched over the situation. The woman got on the stretcher and the EMT placed a blanket over her. As this played out, the policeman stood in the background, allowing the EMT to take primary responsibility for the interaction. Since the woman seemed to pose little risk to herself or others, the response seemed to be the appropriate one. 

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