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Tag: Michael Millenson

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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The Dangerous Patient Safety Delusions of Eminence-Based Medicine

The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.

They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.

They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.

Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.

To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…

Key for Health IT Entrepreneurs: Don’t Disrupt the Wrong Thing

millenson-headshotAmong the 200 demos, 60 exhibitors and more than 100 speakers at the annual Health 2.0 conference on digital health, a critical insight for succeeding in this burgeoning market might have gotten lost in the noise.

The crucial advice came on separate days from two of the savviest digerati doctors in Silicon Valley. Not coincidentally, both Dr. Robert Wachter and Dr. Michael Blumpractice at the University of California, San Francisco (UCSF) Medical Center.

Wachter, an internist, was an early and eloquent advocate of the potential of electronic health records (EHRs) to improve the safety and quality of care. Actual EHR implementation, however, brought not nirvana, but a jarring number of “side effects.” Not least was the way the technology often distracts, confuses and complicates the lives of clinicians, endangering patients in the process.

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Diagnostic Error: The IOM Talks Trash (But Not Cash)

flying cadeuciiTo understand how a landmark new report on diagnostic error breaks the mold, go past the carefully crafted soundbite ­(“Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”) and rummage around the report’s interior.

You can’t get much more medical establishment than the Institute of Medicine (IOM), also called the National Academy of Medicine, author of the just-released Improving Diagnosis in Health Care. Yet in a chapter discussing the role played in diagnostic accuracy by clinician characteristics, there’s a shockingly forthright discussion of the perils of age and arrogance.

“As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process,” the report says. Personality factors can cause errors, too: “Arrogance, for instance, may lead to clinician overconfidence.”

Wow. Sure, both those assertions are extensively footnoted and hedged later with talk of the importance of teams (see below). Still, given the source, this practically qualifies as “trash talking.”

Of course, those quotes didn’t make it into the press release. There, inflammatory language was deliberately avoided so as not to give opponents any easy targets. (Disclosure: I was an advocate of an IOM report on this topic while consulting to an organization that eventually helped fund it. After testifying at the first committee meeting, I had no subsequent involvement.)Continue reading…

How to Out-Argue Your Doctor with Data

Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”

Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.

Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.

In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.

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