- Very Bad Numbers by Anish Koka, MD
- What Would a Health Care Mutual Look Like? by Munk, MD
- A Health IT Developer’s Confession: How Bad Software Is Made and What to Do About It by Margalit Gur-Arie
- Think Again: Health Insurers Have No Reason To Reduce the Price of Health Care by JK Wall
- This Visit May Be Recorded by Alan Schwartz and Saul Weiner
- Saving Normal by Saurabh Jha, MD
- The Right Not to Know by Benjamin Berkman
Would Patients Pay For This?
Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.
Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.
It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?
The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.
The War on Death
Thomas Hobbes described life as pitifully “nasty, brutish, and short.” Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, brutish, and long.
Surgeon and writer, Atul Gawande, explores the medicalization of ageing and death in Being Mortal. Gawande points to a glaring deficiency in medical education. Taught to save lives and fight death, doctors don’t bow out gracefully and say enough is enough. We’re not taught about dying. We’re taught about not dying.
In our lexicon, life is a constant war against the Grim Reaper. We say inactivity kills; screening saves lives; an intervention reduces mortality by 5 %—an arithmetic impossibility as mortality for our species, barring select prophets, remains 100%. Words have precise meanings. Words also hide precise desires. It’s not that we can’t distinguish between a murderer and colorectal cancer; but by giving cancer moral agency—we wage war on cancer—we imply that death is an anomaly that must be fought.
And we fight. We fight death in the hospices. We fight death in the hospitals. In many parts of the world, more people die in hospitals than in their homes. Some die, attached to a noradrenaline infusion, in the CAT scan—the last pit stop of hope between the intensive care unit (ICU) and the morgue.
2016 Obamacare Outlook
One of the more Obamacare fluent reporters just emailed me a set of questions regarding the 2016 outlook for Obamacare.
I thought I would share my responses with you:
According to early CMS data, 38% of exchange enrollees are under age 35. Is the risk pool beginning to stabilize?
It’s too soon to know if the pool is beginning to stabilize. First, the administration’s announcement that 38% of the pool is below age 35 is disingenuous. They are counting all of the children that show up on the rolls with their families. They did not give us the far more important age 18-to-35 number.
Second, the overall subsidy eligible exchange penetration stood at about 35% at the end of 2015. Ideally, Obamacare needs to about double its penetration of the eligible to assure a balanced pool of the sick and the healthy.
Then of course, we always see these big enrollment numbers being announced by the administration only to see the block shrink dramatically by year-end.
So, it will really be a year before all of the dust settles on the 2016 enrollment and we really know what the claim levels are relative to the premiums being charged.
If rates increase too much in 2017, will those young people jump ship?
I worry more about the really poor take-up rates for the healthy people who have not signed up in the 200% of federal poverty level and above brackets than I worry about the percentage of the young who have signed up. Way too much emphasis is put on this age 18-to-35 statistic. Yes, they are more often healthy but under Obamacare the youngest pay one-third the premium of the oldest. We really need the healthy to sign up in much bigger numbers, that have so far been holding out, more than we need the young.
Like Uber for Health Care With Sherpas?
2015 was a hard year for my father. He’s a remarkably healthy 89 year-old, with no diabetes, no hypertension, and (most importantly) he’s got a sharper mind than I do on most days. Perhaps that’s a low bar to cross, but it’s pretty good for him. I think this is from all the crossword puzzles he’s done over the years.
Dad’s troubles started around the middle of the year when he started having low back pain. This pain progressed from mild pain to being so severe that he required a wheelchair to get around the house. This is the man who, a year after breaking a hip, was impossible to keep off of a stepladder to fix something on his roof. It was a big change. After trials of conservative treatment, he was eventually diagnosed with a compression fracture of his lumbar spine (presumably from steroids he took for an inflammatory problem).
Given the severity of his pain, he ended up going to a back specialist to get a procedure to fix the compression fractures and, presumably, reduce his pain. Unfortunately, his pain increased and changed after the procedure. It got so bad, in fact, that he ended up being hospitalized in November for pain control.
The hospitalization was confusing for both him and me. It wasn’t clear if his pain was from a problem in his back, as it had moved to his leg. Yet while in the hospital he didn’t get any radiological study to determine the source. Plus, he’s quite resistant to the effects of narcotic pain medications. I really don’t like to intervene on behalf of family members unless it’s absolutely necessary, but I finally ended up talking to the hospitalist who was quite nice, but not much help. Dad was being discharged to rehab the next day and I still wasn’t clear on what was wrong after a week in the hospital.
What Would a Health Care Mutual Look Like?
For a few years I’ve been fantasizing about what a healthcare insurance/ delivery mutual would look like. I’ve yet to see one but I like the idea a lot.
Here’s the idea behind a mutual: A mutual structure means that the company is owned by its clients or policyholders. Since a mutual’s customers are also its owners, they get to share in any surpluses though they are mostly reinvested in the business.
Wikipedia has a nice writeup on the fundamentals of mutuals:
A mutual exists with the purpose of raising funds from its membership or customers (collectively called its members), which can then be used to provide common services to all members of the organization or society. A mutual is therefore owned by, and run for the benefit of, its members – it has no external shareholders to pay in the form of dividends, and as such does not usually seek to maximize and make large profits or capital gains. Mutuals exist for the members to benefit from the services they provide and often do not pay income tax.
Mutual structures are most common in the banking (credit unions) and insurance industries. The main advantage to mutuals, as compared to public or privately held businesses is that they avoid the “principal-agent” problem (where the company’s desire to serve itself and the customer are at odds).
In a mutual, customer and owner are one.
Mutuals have been around for a few hundred years: “friendly societies” have been active in the UK and the US for a couple hundred years. Friendly Societies… were the original form of social network, where a group of people contributed to a mutual fund, to then receive benefits at a time of need.
Why I Left My Health Care Executive Role to Join a Startup
Six months ago, I made the decision to join a digital health startup, after directing the inpatient EHR roll-out at the University of California San Francisco (UCSF) Benioff Children’s Hospital. This may not seem that surprising: there is a lot of discussion lately of the growing dissatisfaction among doctors with the healthcare system, and “digital dropouts” leaving medicine to work in tech.
The difference is that I am neither 28 nor right out of residency. I’m a 40-year-old healthcare executive who is squarely mid-career, and I did not make the change for the usual reasons: the lure of money, job dissatisfaction, etc. I loved my job at UCSF, and in fact, I continue to see patients there. So why did I leave a promising academic career for a riskier role at a startup? Because we need more seasoned clinicians at the front lines of digital health to get us to scale. Our institutions have made huge financial investments, and now it’s time for us to make a more personal commitment.
Changes In Work Hours and Employer Insurance Not Borne Out
Today, two AHRQ-sponsored studies were released that conclude that the Affordable Care Act (ACA) has not reduced the availability of full-time work or the work incentive for low-wage workers.
In the first study, researchers examined the effects of the requirement in the ACA for employers to provide health coverage to employees working at least 30 hours a week or pay a penalty. Using data from the Census Bureau’s Current Population Survey, an interview of approximately 60,000 households monthly, researchers did not find increases in the frequency of working either 25-29 hours weekly or fewer than 25 hours weekly in 2013, 2014 or the first half of 2015. Researchers also did not find a reduction in 2014 or 2015 in the frequency of working 30-34 hours, further demonstrating that employers have not reduced employee work hours below the 30-hour threshold to avoid the requirement to provide coverage.
In the second study, researchers assessed the impact of the expansion of Medicaid coverage on low-wage workers by analyzing job loss, job switching, and full- versus part-time status. Based also on data from the Census Bureau’s Current Population Survey, researchers compared states that had not expanded the program to states that have done so. The researchers found no statistically significant changes in labor market behavior as a result of Medicaid expansion, contrary to claims that the law would substantially reduce labor supply.
False Positive Mammograms and Cancer Risk: An Epidemiological Whodunit
I enjoyed Agatha Christie’s Hercule Poirot. Not only did the ingenious Belgian solve the murder so artfully. But someone identifiable is killed and someone identifiable is the killer.
Epidemiological studies are whodunits, too. Except you don’t know who has been killed, what the murder weapon is, or who the killer is. You only know that a murder may have happened.
A study found a higher incidence of breast cancer with false positive than true negative mammograms. Meaning false positive findings – findings thought to be cancer but aren’t – should lead to vigilance, not celebration.
Here’s an image to help put the absolute difference in perspective: If in the right aisle of a hall there are 600 women with false positive and in the left aisle 600 women with true negative mammograms, one extra woman in the right aisle will develop cancer over 10 years. Once we factor lead time and overdiagnosis, the extra cancer will probably not reduce longevity.
Whether it is the tiny benefit of statins or a tiny absolute risk increase in epidemiological studies, no effect is too small to fret about. The authors, to their credit, handled the results modestly and merely suggested that a false positive status be used in predicting risk of cancer — not that the false-positive result itself somehow causes an increase in cancer risk.
Effect size correlates poorly with media sensationalism. Media coverage was extensive, partly because false positives increasing cancer risk is Twilight Zonish – just when you thought it was safe to go outside.
Matthew’s Issues & Charities at end 2015, start 2016
Every year (well almost) I write a letter to friends and contacts about which charities I give to and which issues I support, and recently I’ve been posting it on THCB–hey I own the joint so who’s going to stop me!. Here’s this end/start year edition–Matthew Holt
Yes another year with a Matthew issues letter nearly missed but not quite. I’m poolside in Maui winding down as much as possible when on a vacation with little kids and I’ve missed getting this out for end 2015 but because of the weekend 2016 isn’t really here yet, and I’m finally hammering out my end of year news, gossip, charities and issues letter. A couple of weeks ago someone asked me how the new year was shaping up, and I told them I was about ready for 2012….and I still feel the same way. I seem to spend more time reading articles on the habits of productive people than actually being one …thanks Buzzfeed!
If you don’t know, this is a letter I write mostly to myself about what happened in what’s now last year and what I should do about it–in terms of making charitable donations while it’s still 2015, although I must confess that I sometimes give money on Jan 1-2 and claim it on my taxes for the year before, so I hope the NSA isn’t sharing this email with the IRS. People do ask me about it every year, sometimes in advance, so hopefully it’s not a waste, and if you don’t care then hit delete, or go onto the next fascinating Facebook article on 15 celebs that look gross after plastic surgery, or whatever….and I love comments on the blogs/Facebook/Twitter or by email, so please let me know what you think.
The main stuff is the issues below, but quick update on me and mine. Aero (1), Coco (4) and Amanda (unspecified) still continue to interrupt my attempts to waste my life away. Amanda says that my appeals for a diaper changing robot are unnecessary as Aero only has about 2,000 changes to go. She does say though that I might soon need one, Health 2.0 had a great year with our biggest ever crowd in Santa Clara plus 2 other successful conferences in the US plus others in Europe (Barcelona) Korea, Latin America (São Paolo) and Japan, where I had great fun this November. I also snuck in a trip to Finland to talk about Health 2.0 (12 mins of fun here) at the wonderful SLUSH conference and had a cold plunge after a sauna, leading to my most viewed and commented Facebook video post ever! (Thanks to my host Pekka Sivonen). Thanks to everyone who worked for, volunteered at, spoke at or came to a Health 2.0 conference.
In addition due to the work of my long suffering partner Indu Subaiya, and our New York team led by Graeme Ossey & Jen David we now have a really vibrant business running challenges and pilots, including a huge new project for the World Bank exposing hospitals in India to new technology. You can also very occasionally see me write on The Health Care Blog which I own while John Irvine manages it (well sort of!!)
But this email isn’t about that, it’s about about issues, charity and politics—I missed end of 2013 but 2014’s was pretty good, so much of this is a minor update. If you want to see the past editions here’s 2012, 2011 201
Health care & (poor) women’s & kids care
The affordable Care Act is finally established, having survived yet another crazy attack in the Supreme Court. And in the most expensive and inane way basically 10 more million Americans have health insurance than did before. But before you criticize, realize that this was the best that could be done given the insane politics of America and that, other than the disgraceful refusal by many southern Republican governors to expand Medicaid in southern states leaving many of the very poor uncovered, almost everyone now has the chance to be in the system–including those people who had health conditions who were previously left to go broke or die. America hasn’t done entirely the right thing yet, but we are getting there.
What sadly has come into focus this year is the desperate attempts to attack women’s access to health care. If you’re a woman– especially a young or poor one who needs access to contraceptives, mammograms, cervical cancer screening, sexually transmitted disease testing, and all kinds of health procedures including safe abortions, it’s become the mission of mainstream Republicans to stop you getting them–using disgusting, deceitful, and downright illegal methods. And that’s as polite as I can say it. So my biggest bump in funding this year went to the one organization that consistently not only campaigns for but actually provides reproductive health services (including contraception, STD testing, counseling, pregnancy support and, yes, safe abortions), Planned Parenthood. I cannot believe that men want to live in a world where women cannot get these services, although I guess the evidence shows enough do….especially in Texas, Louisiana, Indiana and many more.
Finally Coco’s first pediatrician, the amazing Nadine Burke Harris just got a big grant to study the impact of Adverse Childhood Events.. Worth checking out some information about that here (no donation required!)
