Category: Uncategorized

You are Solving the Wrong Problem

Nov 14, 2011• 12

By Aza Raskin

There is some problem you are trying to solve.

In your life, at work, in a design. You are probably solving the wrong problem.

Paul MacCready, considered to be one of the best mechanical engineers of the 20th century, said it best: “The problem is we don’t understand the problem.”

Story time.

It’s 1959, a time of change. Disney releases their seminal film Sleeping Beauty, Fidel Castro becomes the premier of Cuba, and Eisenhower makes Hawaii an official state. That year, a British industry magnate by the name of Henry Kremer has a vision that leaves a haunting question: Can an airplane fly powered only by the pilot’s body power? Like Da Vinci, Kremer believed it was possible and decided to push his dream into reality. He offered the staggering sum of £50,000 for the first person to build a plane that could fly a figure eight around two markers one half-mile apart. Further, he offered £100,000 for the first person to fly across the channel. In modern US dollars, that’s the equivalent of $1.3 million and $2.5 million. It was the X-Prize of its day.

A decade went by. Dozens of teams tried and failed to build an airplane that could meet the requirements. It looked impossible. Another decade threatened to go by before our hero, MacCready, decided to get involved. He looked at the problem, how the existing solutions failed, and how people iterated their airplanes. He came to the startling realization that people were solving the wrong problem. “The problem is,” he said, “that we don’t understand the problem.”

THCB Live

Nov 14, 2011

Earlier this month, Chicago Mayor Rahm Emanuel talked about the innovative ways his administration is using health IT to fight rising healthcare costs. In his address, Emanuel announced that Merge Healthcare will donate 100 health kiosks to the city of Chicago. The kiosks are internet-connected health stations where consumers can check their vitals, including weight, BMI, blood pressure and heart rate for free.

Wal-Mart Care

Nov 14, 2011• 24

By John Goodman

Can Wal-Mart provide us with health care as efficiently as it furnishes us with paper towels?

According to a Kaiser Health News report:

Wal-Mart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a document obtained by NPR and Kaiser Health News.

But then the next day, according to Kaiser, the company started backtracking:

The only thing the company would say for certain is: “we are not building a national, integrated, low-cost primary care health care platform,” according to the statement from to John Agwunobi, senior vice president and president of Wal-Mart U.S. Health & Wellness.

I’ll get to what Wal-Mart might be thinking in a minute. First questions first: Can Wal-Mart provide care that is of higher quality and lower cost than conventional provision? If so, how?

My answer: Wal-Mart can indeed improve on the current system. But here’s the catch. It can do so only if it continues doing what it and other retail medical outlets are already doing: ignore the third-party payers. Almost everything that’s wrong with our health care system is the direct result of third-party payment; and some of the most striking examples of efficient care are emerging in those parts of the market where third-party payment is either nonexistent or of marginal importance.

So as not to be misunderstood, I am not saying that our problems are being created by health insurance. There is nothing in principle wrong with insurance. The source of our problems is using insurance companies to pay medical bills. It’s insurance companies acting pro emptore — in place of the buyer.

Understanding the Supreme Court’s Health Law Review

Nov 14, 2011• 2

By Stuart Taylor, Jr.

By agreeing today to hear challenges to President Obama’s 2010 health care law, the Supreme Court set the stage for a decision — probably in late June and in the midst of the presidential campaign — that could be among its most important in decades.

The case, which will probably be argued in March on a date still to be announced, is especially momentous because it not only will determine the fate of President Barack Obama’s biggest legislative achievement but also will cast important light on the Supreme Court’s future course under Chief Justice John Roberts on issues of federal government power.

The central issue — but not the only important one — is whether Congress exceeded its constitutional powers to regulate interstate commerce and to levy taxes when it adopted the so-called “individual mandate” at the heart of the health care law.

That provision would require millions of people starting in 2014 to buy commercial health insurance policies or pay financial penalties for failing to do so.

The court also agreed to decide a challenge to the Affordable Care Act’s provision essentially requiring states greatly to expand their Medicaid spending.

The court made clear that if it decides to strike down the individual mandate or Medicaid provision, it will also decide which of the 975-page law’s hundreds of other provisions should go down too, by divining whether Congress would have wanted some or all of them to be effective even without the voided provision or provisions.

SCOTUS: Big News Is the Medicaid Grant

Nov 14, 2011

By BRADLEY JOONDEPH

So here are the two biggest consequences of the order:

* The Court has limited itself to the Florida case, and is presumably holding theThomas More Law Center and Liberty University petitions. (It will likely need to appoint someone to argue the AIA question against the parties.)

* The Court granted on the Medicaid question. This is a bit of a surprise, raising the constitutional stakes of the case rather substantially. For if the Court were cut back on Congress’s spending power, it would have significant long-term ramifications for the scope of federal power.

Again, the really big news of the morning — if there is anything surprising — is that the Court has decided to take up the constitutionality of the ACA’s Medicaid amendments. Specifically, the question is whether the spending conditions that the ACA imposes on the states are effectively “coercive,” such that they amount to an impermissible commandeering. There is no split on the question, and no lower court judge has yet voted to uphold the states’ claim. But the Court will take it up.

As a purely legal matter, this is a bigger issue than the individual mandate. For much of the modern liberal state is undwerwritten by Congress’s use of the conditional spending power.Continue reading…

Rethinking Medical Education

Nov 11, 2011• 25

By Victor R. Fuchs

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care. His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.” He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist. Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care. Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes.

I expressed similar concerns in 1974 in my book Who Shall Live?, but at that time I rejected the claim that the problems of medical care had reached crisis proportion. In 2011, however, I agree with those who say the need for comprehensive reform must be marked URGENT. The high and rapidly rising cost of health care threaten the financial credibility of the federal and state governments. The former finances much of its share of health care by borrowing from abroad; the states fund health care by cutting support of education, maintenance of infrastructure, and other essential functions. These are stop-gap measures; neither borrowing from abroad nor cutting essential functions are long-run solutions. The private sector is equally distressed. Surging health insurance premiums have captured most of the productivity gains of the past thirty years, leaving most workers with stagnant wages. Not only is there a pressing need for changes in organization and delivery, but Ezekiel Emanuel and I, in our proposal for universal vouchers funded by a dedicated value-added tax, argue that such changes must be accompanied by comprehensive reform of the financing of medical care (Brookings paper).

But that’s not what I want to talk to you about today. My subject is the urgent need to change the structure of medical education. It seems to me that such change is necessary, and perhaps inevitable, given the revolution in medicine over the past half century, and given the changes in organization and delivery of care that lie on the horizon.

America Needs Different Doctors. Not More Doctors.

Nov 11, 2011• 43

By Merrill Goozner

Matt Yglesias at Think Progress took a look at some OECD data comparing U.S. physicians to their international counterparts and concluded we need more doctors. The evidence? There’s only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). At the same time, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay a lot for health services including physician services (he reprints a chart showing average pay for U.S. physicians, whether highly paid orthopedic surgeons or relatively poorly paid primary care docs, that shows they are the highest paid among six well-off OECD countries). But his conclusion that America therefore needs more docs is off the mark.

This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent visit to Japan, I visited a community clinic in Kumamoto Prefecture on Kyushu that gives local citizens their annual wellness exam, which is reimbursed under their national health care system. Every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.

The Doctor Is In (And Extremely Annoyed)

Nov 9, 2011• 19

By John Maa, MD

On a Saturday around noon, an 85-year-old woman was brought by ambulance to the Emergency Department with severe abdominal pain. She was confused and unable to provide any medical information. Her X-rays showed marked accumulation of abnormal air in her abdomen, a dreaded sign of a perforation in the intestinal tract. Her blood pressure was quite low, requiring treatment with intravenous medications. As the general surgery intern on call, I was asked to see her.

A physical examination showed her abdomen was rigid and extremely tender, which confirmed this was a surgical emergency. Laboratory testing indicated a serious infection, likely the result of intestinal contents leaking into the abdomen, as well as mild kidney injury. Multiple efforts to reach either family or friends by telephone were unsuccessful, and a conservator or someone with durable power of attorney could not be identified to provide informed consent. The patient clearly needed surgical intervention, so two surgeons wrote notes documenting the need to bring her immediately to the operating room as this was a “life-threatening emergency situation.”

During a 6 hour procedure in the operating room, she underwent repair of a benign perforated ulcer in her stomach. She was brought to the recovery room with the breathing tube in place only because it was late in the evening, with the plan to remove the breathing tube promptly in the morning. I saw her during a post-operative check around 9pm, and all seemed to be improving. She was now requiring much lower doses of medications to maintain an adequate blood pressure, and her kidneys were recovering with a good urine output.

About an hour later, I was notified by the nurses that the patient’s children had arrived. They demanded immediate withdrawal of support. One produced paperwork indicating that she was her mother’s durable power of attorney. She stated that her mother would never have wanted to be “on life support, intubated, and in need of dialysis or blood pressure medications to artificially maintain her blood pressure”.

Appellate Court Upholds ACA In Opinion By Prominent Conservative Judge

Nov 9, 2011• 8

By TIMOTHY JOST

Yesterday, November 8, the United States Court of Appeals for the District of Columbia became the second federal court of appeals to uphold the constitutionality of the minimum coverage requirement of the Affordable Care Act.

To date, one federal appellate court has held the minimum coverage requirement to be unconstitutional (although severable from the remainder of the ACA), while five other appellate court decisions have held that the courts lacked jurisdiction to consider the challenge brought to them, either because the plaintiffs in the particular case had not been injured by the minimum coverage requirement or because a federal statute, the Anti-Injunction Act, denies jurisdiction.

This is a very important decision. Judge Laurence Silberman, who wrote the majority opinion upholding the statute, is a highly-respected conservative judge, appointed by President Reagan. Judge Harry T. Edwards, a Carter appointee, joined Judge Silberman in the majority. Judge Brett M. Kavanaugh, another well known conservative judge appointed by George W. Bush, dissented in an opinion that was much longer than the majority opinion, but on jurisdictional grounds rather than on the merits. Kavanaugh would have held, as the Fourth Circuit did in the Liberty University case, that the Anti-Injunction Act deprives the federal courts of jurisdiction. In the course of his lengthy opinion, Judge Kavanaugh suggests that there may be prudential as well as legal reasons why the courts may want to stay out of this fight, and suggests that if there is in fact a constitutional defect with the ACA (which he does not decide), it could be easily fixed by Congress.

This decision comes down two days before the Supreme Court will consider, and quite possibly decide, whether or not to take certiorari in one or more of four other appellate court cases that have been decided in ACA challenges. Although a grant of certiorari is almost certain at this point, the D.C. Circuit’s decision, as well as the earlier opinion of Judge Jeffrey Sutton, another prominent conservative who sided with the constitutionality of the ACA in a Sixth Circuit case, will certainly be noted by the Supreme Court justices. Moreover, the media narrative that seemed to explain the district court opinions—Republican appointees strike down the law while Democratic appointees uphold it—seems again not to work for appellate court judges. It may not work for predicting the Supreme Court vote either.

Walmart Wants To Be Nation’s Biggest Primary Care Provider

Nov 9, 2011• 45

By Julie Appleby and Sarah Varney

Walmart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a confidential company document.

In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

The 14-page request asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.

Analysts said Walmart is likely positioning itself to boost store traffic – possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.

“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”