Category: Uncategorized

Saving Normal

Dec 16, 2015• 8

By SAURABH JHA, MD

The iconoclastic psychiatrist Thomas Szasz said that mental illness was metaphorical, not real, because mental diseases lacked biological substrates. The absence of a substrate predisposes psychiatry to overdiagnosis and avoiding overdiagnosis is psychiatry’s biggest challenge. This challenge has been taken up by Allen Frances in Saving Normal. Like Szasz, Frances writes in cultured, erudite prose. Unlike Szasz, Frances believes that psychiatric illnesses are real. To save the mentally ill, to save psychiatry from itself, Frances says we must save normal.

Six years ago, Frances was enjoying retirement after a distinguished career, minding his business sipping cocktails at the annual meeting of the American Psychiatric Association (APA). Psychiatrists were excited about updating the Diagnostic and Statistical Manual of Mental Disorders (the soon to be DSM-V). Frances had chaired the previous edition of DSM, but in the zeal of the latest edition, he saw diagnostic hyperinflation of a frightening scale.

Why Doctors should Recommend Quantified Self Technologies for Their Patients

Dec 16, 2015

By MOLLY MALOOF, MD

The United States population suffers from staggering numbers of lifestyle related diseases. We know the situation is not improving. Recent research found that over half of the country has prediabetes or diabetes. The facts don’t lie—the vast majority of the US burden of disease are due to lifestyle.

Photo Credit: Dr. DArriush Mozzafarian

People know they should eat less and exercise more, but they don’t. They don’t because without the right knowledge and direction, behavioral change is really hard. Doctors also know they should be advising their patients on lifestyle, but they don’t.

Genetic Testing: The New Frontier of Wellness Madness

Dec 16, 2015• 4

By AL LEWIS

The Wall Street Journal just reported that Genetic Testing May Be Coming to Your Office Soon. This is all well and good, assuming employees would want their health insurer’s buddies collecting their DNA for no good reason, handling it, selling it, and possibly losing it. This is not us talking. This is what the testing company itself says on their website. You can read all about it here.

Instead we will focus on the fact that this scheme simply doesn’t save money – according to the main proponents of this dystopian scheme, Aetna and its buddies at the ironically named Newtopia. Anticipating the day (yesterday) that this would become front-page news, we have already showed how Aetna’s study accidentally showed the opposite of what it intended to show. This is that proof.

The Right Not to Know

Dec 15, 2015• 1

By BENJAMIN E. BERKMAN

While promising to eventually revolutionize medicine, the capacity to cheaply and quickly generate an individual’s entire genome has not been without controversy. Producing information on this scale seems to violate some of the accepted norms governing how to practice medicine, norms that evolved during the early years of genetic testing when a targeted paradigm dominated. One of these widely accepted norms was that an individual had a right not to know (“RNTK”) genetic information about him or herself. Prompted by evolving professional practice guidelines, the RNTK has become a highly controversial topic. The medical community and bioethicists are actively engaged in a contentious debate about the extent to which individual choice should play a role (if at all) in determining which clinically significant findings are returned.

In a recent paper published in Genetics in Medicine, my coauthors and I provide some data that illuminates this and other issues. Our survey of 800 IRB members and staff about their views on incidental findings demonstrates how malleable views on the RNTK can be. Respondents were first asked about the RNTK in the abstract: “Do research participants have a right not to know their own genetic information? In other words, would it be acceptable for them to choose not to receive any GIFs?” An overwhelming majority (96%) endorsed the right not-to-know. But when asked about a case where a specific patient has chosen not to receive clinically beneficial incidental findings, only 35% indicated that the individual’s RNTK should definitely be respected, and 28% said that they would probably honor the request not to know. Interestingly, the percentage of respondents who indicated that they do not support the RNTK increased from 2% at baseline to 26% when presented with the specific case. The percentage of people who are unsure similarly jumps, from 1% to 11%.

Physician Burnout Rates Top 50% in latest Mayo Study

Dec 15, 2015• 8

By DIKE DRUMMOND, MD

Over 50% of US Physicians now suffering at least one symptom of burnout. Depression and suicidal ideation rates even more concerning.

For a while now I have been suspicious that physician burnout rates are increasing here in the USA, especially in the last five years or so. There is just too much political chaos, marketplace M&A activity and documentation overload for it to be otherwise.

Finally the research has caught up with this suspicion in the latest version of Mayo’s landmark 2011 physician burnout study. Here is our smoking gun at last. Unfortunately the numbers are bad and the burnout numbers, though mind boggling, are not the most concerning finding.

Mayo Clinic Proceedings this month published results of round two of their survey of burnout in physicians compared to burnout in the “normal population”. The first round in 2011 was major news across the country and the first study that compared physician burnout rates to those of non-physician workers.

The burnout rates are what I expected. The shocker is the number of physicians screening positive for depression and suicidal ideation that no one is reporting on.

The Profitability (or Not) of Harming Patients

Dec 14, 2015

By MICHAEL L. MILLENSON

When the government announced recently that a patient safety partnership with hospitals had saved 87,000 lives and nearly $20 billion over four years, there was an oblique reference to the role played by “financial incentives.”

Left unsaid was that a quiet effort has been going on for years to persuade hospitals they can make more money preventing harm than by allowing it to occur. In recent years, that’s included articles in the medical literature looking at the profitability of preventing serious bloodstream infections in critically ill infants in the neonatal intensive care unit(NICU) and in kids with leukemia.

For adults, there have been analyses of the financial impact of serious infections and surgical complications. In a presentation I heard earlier this year, a vendor mentioned the return on investment (ROI) of a technology that more rapidly detects when a post-surgical patient unexpectedly stops breathing.

HEART for the Stage 3 API

Dec 14, 2015• 3

By ADRIAN GROPPER, MD

It is imperative that we support the interoperability components of Meaningful Use Stage 3. The promise of reform to justify our massive investment in MU must be supported by broad, patient-centered interoperability mandates so that “data follows the patient”. The Stage 3 API requirement will be the centerpiece of interoperability because only patient-directed exchange can solve the challenges of patient matching and governance as described in the recent General Accounting Office report.

The Stage 3 API requirement will serve both patients and providers by enabling patients to delegate access to their records on the API to anyone, including apps, providers, and other EHRs. The vision for how this will happen is taking place in two workgroups: the OpenID Foundation Health Relationship Trust (HEART) and ONC’s API Task Force.

How this will work is the subject of a HEART use-case titled Elderly Mom with Family Caregiver. Based on the Kantara User Managed Access (UMA) and the HL7 FHIR standards, HEART profiles for healthcare are the foundation for broad interoperability and improved cybersecurity.Continue reading…

This Is America: You Don’t Have to Do Anything You Don’t Want To

Dec 13, 2015

By HANS DUVEFELT, MD

“I just want you to know, I won’t have a colonoscopy”, my new patient said with some amount of fervor in his voice. “And I don’t want to take a lot of medications.”

I looked him straight in the eyes and said “This is America, you don’t have to do anything, and I work for you. My job is to help you know your options.”

He seemed to relax. I reflected on the words I had just uttered, yet another time – it is the way I often try to set the tone as a non-authoritarian, patient focused physician.

“You don’t have to do anything”, of course, only applies to the patient.

The doctor has to do a lot of things, like document a treatment or follow-up plan for Medicare patients with a BMI over 30, or provide computer generated patient education to a minimum percentage of patients, and achieve a certain percentage of e-prescriptions. And right about now, we are starting to see financial consequences if too many of our patients, like the man I had just met, don’t want to take the medications that can bring their blood pressures or blood sugars below certain targets.

Headlines We’ll See In 2016

Dec 13, 2015• 3

By PAUL KECKLEY

Amidst the rhetoric of Campaign 2016, the reality of escalating health costs, and the acceleration of consolidation across the industry, healthcare headlines in 2016 will highlight major changes that will reshape the future for the next decade and beyond. Here’s the top 10 you can expect to read next year:

Insurance Mega-Deals Approved, Blues Align more Tightly to Compete:

The Department of Justice approved the mega-deals allowing Anthem’s acquisition of Cigna and Aetna’s takeover of Humana. With certain provisions, the deals will go forward which means United, Anthem and Aetna will together control 44% of the U.S. insurance market. In response, the Blue Cross Association announced it is moving forward with its plans to create a more cohesive national strategy for its 36 members to compete with the Big 3. Collectively, the four serve 242 million members, or more than 80% of the insurance market in the U.S.

America’s Bitter Pill: CBO was Right. The White House and Steven Brill Were Wrong.

Dec 11, 2015• 19

By KIP SULLIVAN

Steven Brill’s latest book, America’s Bitter Pill, is a frustrating mix of excellent history and muddled health policy analysis. The book is a very good addition to the literature on the history of the Affordable Care Act and by far the best reporting I’ve read on the bungled implementation of the federal health insurance exchange. But Brill’s analysis of why the ACA cannot reduce health care costs is naïve and confusing. Brill claims a few smart men on the White House “economic team,” including Peter Orszag and Ezekiel Emanuel, fought hard to push “game-changing” cost-containment into the ACA but were defeated by others who were less interested in cost containment.

That explanation is wrong on two counts:

(1)There was little evidence in 2009, and little today, to support the claims by Orszag et al. that the methods they promoted would cut costs;

(2) The ACA in fact contains most of what Orszag et al. fought for.

What Brill unquestionably gets right is his conclusion that the ACA cannot cut costs. He makes his conclusion clear at the end of the book. He quotes this astonishing statement by Obama – “Frankly what we’ve seen in progress on costs has surpassed almost anybody’s most optimistic expectations” – and then unceremoniously rejects it. “But there is actually little evidence of that,” he writes. (p. 416)