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Tag: Michael Millenson

What Baseball Can Teach Doctors

Baseball, like medicine, is deeply imbued with a sense of tradition, and no team more so than the New York Yankees, disdainful of innovations like placing players’ names on the backs of their jerseys and resistant to eroding strict standards related to haircuts and beards.

It’s why doctors and patients alike should pay special attention to why the Yankees parted ways with their old manager and what they now seek instead. In a word: “collaboration.”

That’s the takeaway from a recent New York Times article examining why the Yankees declined to re-sign manager Joe Girardi despite his stellar “outcomes” (to use a medical term); i.e., the best record in baseball during his 10 years at the Yankees’ helm. But Yankees executives believe the game has changed. The model for future success is the Los Angeles Dodgers, the tradition- and cash-rich franchise on the opposite coast that went to this year’s World Series while the Yankees sat home.

The new way to win? According to Dodgers executives, it requires a combination of statistical analysis, shared decisions and communication between and among all stakeholders based on collaborative relationships.

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Could OpenNotes Transform the Analytics Marketplace?

Could OpenNotes help push predictive analytics from paternalism to partnership?

As new payment incentives make it profitable to prevent illness as well as treat it, new technology is offering the tantalizing prospect of accurately targeting pre-emptive interventions.

At the recent Health 2.0 Annual Fall Conference, for example, companies like Cardinal Analytx Solutions and Base Health spoke of using machine learning to find those individuals among a client’s population who haven’t yet been expensively sick, but are likely to be so soon. Companies seeking to make that information actionable touted their use of behavioral theory to “optimize patient motivation and engagement” via bots, texting and other technological tools.

Being able to stave off a significant amount of sickness would constitute extraordinary medical progress. Along the way, however, there’s a danger that an allegiance to algorithms will reinforce a paternalism we’ve only recently begun to shed. A thin line can separate engagement from enforcement, motivation from manipulation, and, sometimes, “This is for your own good” from “This is for my bottom line.” It is here where OpenNotes could play a critical role.

In a recent article for The BMJ, I proposed a concept called “collaborative health” to describe a shifting constellation of relationships for maintaining wellbeing and for sickness care. Shaped by each individual’s life circumstances, these will sometimes involve the traditional care system, as “patient-centered care” does, but not always.

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It’s Time to Truly Share the Chemo Decision With Cancer Patients

You (or a loved one) has cancer, but the latest round of chemotherapy has unfortunately had only a modest impact. While you’re acutely aware of the “wretchedness of life that becomes worn to the nub by [ chemotherapy’s] adverse effects” you’re also a fighter.

How do you decide whether to continue with chemo?

The answer to that question is both intimately personal and inextricably tied to health policy. Cancer is the leading cause of death among those aged 60 to 79, and it is the second leading cause of death for all Americans. With expenditures on cancer care expected to top $158 billion (in 2010 dollars) by 2020, the financial and emotional stakes are both high.

How do you decide whether to continue with chemo?

The answer to that question is both intimately personal and inextricably tied to health policy. Cancer is the leading cause of death among those aged 60 to 79, and it is the second leading cause of death for all Americans. With expenditures on cancer care expected to top $158 billion (in 2010 dollars) by 2020, the financial and emotional stakes are both high.

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Did Medical Darwinism Doom the GOP Health Plan?

“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”

Although the quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.

Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) declared: “The idea of Obamacare is that the people who are healthy pay for the people who are sick.” Contemporary language, but the same thinking that sank President Harry Truman’s health care plan almost seven decades ago.

Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility.

As a researcher who has documented this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.

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A Purpose-Driven App Tests Work-Life Balance

Your employer sends out an email saying they want to make sure you’re getting enough sleep and physical activity, are eating well and feeling creative and, finally, have a sense of “mindfulness.” So they’re providing a free app designed to facilitate finding your “anchoring purpose in life.”

Sound like a nice perk? Now add in one more detail.

All the information, albeit with individual data de-identified, goes into a giant database meant to boost productivity and reduce medical costs by improving worker physical and mental health.

Any less excited?

The app, from a start-up called JOOL Health, raises the question of when good engagement can bleed into overtones of Big Brother. The answer is complicated.

JOOL is the brainchild of Victor Strecher, a professor of health behavior and health education at the University of Michigan School of Public Health and a successful entrepreneur. Marketed to third parties rather than direct-to-consumer, the app was pitched at a recent consumer experience conference sponsored by America’s Health Insurance Plans (AHIP) as a way to go “from wellness to engaged wellbeing in the Digital Age.”

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Bringing the “Art of the Deal” to Healthcare

Obamacare, at least in its original incarnation, is on its way out. The pressing question now is whether “art of the deal” health care will remain.

“The Art of the Deal” is the title of the 1987 best-seller that catapulted real estate developer Donald Trump to national prominence. Although Trump has denounced Obamacare as a “disaster,” and Republicans have voted for its repeal, their attacks have focused mostly on sections of the Affordable Care Act that expanded access to health insurance.

At least as important, however, are the lesser-known parts of the law that have let Medicare use its financial clout to push for better, safer, and less expensive medical care. In Trump’s terminology, it’s been a “terrific deal” for anyone who’s seen a doctor or gone into the hospital, saving a staggering 125,000 lives and $28 billion in just four years, according to the Department of Health and Human Services.

Unfortunately, Trump’s pick as HHS secretary, orthopedic surgeon and Georgia Republican Representative Tom Price, appears at best a lukewarm supporter of this approach. Will Trump protect Americans’ great health care deal? Or might Price be the first cabinet secretary to hear, “You’re fired!”?

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Making Cancer Care Great Again

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Q: Donald Trump’s campaign for the presidency included a promise to repeal “Obamacare” in its entirety. If he succeeds in fulfilling that promise, what impact can we expect on American cancer prevention and cancer treatment?

A: Donald Trump, emboldened by eliminating ISIS, ending illegal immigration and energizing the economy, will eradicate cancer. Or at the very least, I predict, he will append it to his list of promised achievements as president.

Our current chief executive, dubbed “No Drama Obama” by his staff during the 2008 campaign, couldn’t resist the heady promise of a cancer “moonshot.” Trump, who’s declared, “I will take care of ISIS,” “close up those borders” and “jump-start America,” will likely rev up the rhetoric back to Nixonian “War on Cancer” levels.

A candidate whose campaign centered on his personal pledge to “make America great again” will surely be galvanized by the chance to make cancer care “great,” too.

The current Cancer Moonshot initiative, featured in President Barack Obama’s last State of the Union Address, is codified in a presidential memorandum of Jan. 28, 2016 and placed within the Office of the Vice President. While fighting cancer was of deep personal interest to Vice President Joe Biden, Vice President-elect Mike Pence was governor of Indiana, where pharmaceutical giant Eli Lilly has a major portfolio of oncology products. Coincidentally, Lilly in October introduced a new version of its PACE Continuous Innovation Indicator (CII), a customizable, online tool to review progress against cancer in order to inform public policy and accelerate innovation.

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You Won’t Believe What Medicare Just Did on Patient Engagement!

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Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.

And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.

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Making Medicine Great Again

The annual Lown Institute Conference advocates for the “right” kind of patient care, as in “the correct course of action.” But the political meanings of “right” and “left” also echo, sounding like a healthcare version of the recover-lost-glory demands of Donald Trump and the moral crusade of Bernie Sanders.

The program for this year’s meeting, held in Chicago, urged attendees to “take back health [care];” you could almost hear a Trumpian, “Make medicine great again!” In an opening address, the institute’s senior vice president, Shannon Brownlee, proclaimed, “We are gathered out of a shared sense of moral purpose and a shared sense of outrage at the state of American healthcare.” The targets of that outrage that “we” need to take back healthcare from comprised a Sanders-type litany of the “pharma, biotech and device companies…[who] have illegally marketed products.”

There was one more villain, very carefully defined. That would be “a culture of overtesting and overtreatment…[that] harms patients, clinicians and communities.” Got that? While Brownlee’s acclaimed 2007 book, Overtreated, repeatedly highlights the abuses of fee-for-service medicine, the Lown Institute’s namesake founder and its president are academic physicians. And so, the doctors and hospitals responsible for and often profiting from overtreatment magically become just one more set of victims of the “culture.”

Ideological blinders notwithstanding, the institute’s work celebrates and highlights an impressive array of individuals working diligently for every conceivable kind of “right care.” There was Dr. Jeffrey Brenner, a Camden, NJ family physician whose description of his dogged, data-driven efforts on behalf of the poor and sick brought a standing ovation. And Dr. Joanne Lynn, a long-time advocate for the frail elderly, explaining why a MediCaring community model that mixed medical and social services was what the vulnerable old and their families really needed.

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The ACO Information Vacuum

flying cadeuciiIn my three-part series on why we know so little about ACOs, I presented three arguments:

  1. We have no useful information on what ACOs do for patients;
  2. that’s because the definition of “ACO” is not a definition but an expression of hope; and
  3. the ACO’s useless definition is due to dysfunctional habits of thought within the managed care movement that have spread throughout the health policy community.

Judging from the comments from THCB readers, there is no disagreement about points 1 and 3. With one exception (David Introcaso), no one took issue with point 2 either. Introcaso  agreed with point 1 (we have no useful information on ACOs), but he argued that the ACO has been well defined by CMS regulations, and CMS, not the amorphous definition of “ACO,” is the reason researchers have failed to produce useful information on ACOs.

Another reply by Michael Millenson did not challenge any of the three points I made. Millenson’s point was that people outside the managed care movement use manipulative labels so what’s the problem?

I’ll reply first to Introcaso’s post, and then Millenson’s. I’ll close with a plea for more focus on specific solutions to specific problems and less tolerance for the unnecessarily abstract diagnoses and prescriptions (such as ACOs) celebrated today by far too many health policy analysts.

Summary of Introcaso’s comment and my response

I want to state at the outset I agree wholeheartedly with Introcaso’s statement that something is very wrong at CMS. I don’t agree with his rationale, but his characterization of CMS as an obfuscator is correct.

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