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Tag: Michael Millenson

The Emperor’s New Social Network

You can’t get much cooler than HealthTap: slick Silicon Valley start-up, social media darlingsavvy and successful backers. But when you closely examine the service HealthTap actually provides, the money and good looks fall away. Like in the fable about “the emperor’s new clothes,” behind the buzz, there’s nothing there.

OK, maybe one thing: a really risky way to get medical advice.

Here’s how a Feb. 4 New York Times article described the company’s website:

[U]sers post questions and doctors post brief answers. The service is free, and the doctors aren’t paid. Instead, they engage in gamelike competitions, earning points and climbing numbered levels. They can also receive nonmonetary awards — many of them whimsically named, like the “It’s Not Brain Surgery” prize, earned for answering 21 questions at the site.

Fellow physicians can show that they concur with the advice offered by clicking “Agree,” and users can show their appreciation with a “Thank” button.

So far, so good. But there’s more. The professional credentials of the physician answering your question, such as a board-certified specialty, are not available on the site. Instead, you get a crowdsourced “reputation level” built up by accumulating HealthTap awards, by  clicks of approval from other doctors and by other measurable activities at the site.

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The Fine Line Between Shared and Manipulated Medical Decisions

Spend some time with the Society for Medical Decision Making, and “shared decisions” starts to seem less a clinical ideal and more an offshoot of picking a monthly cell phone plan. The fine line between “motivating” and “manipulating” behavior (albeit sometimes unintentionally) starts to blur.

At the group’s recent annual meeting in Chicago, the differing sensibilities of medical and marketplace ethics were in plain view on a panel entitled (with a nod to the Richard Thaler and Cass Sunstein behavioral economics best-seller), “From a Nudge to a Shove: How Big a Role for Shared Decision Making?”

Peter Ubel, a physician and a professor of marketing and public policy at Duke University, told how some free-market theorists have defined away, “overweight.” Since people know what causes them to put on pounds, goes this reasoning, the weight they are must be the weight they rationally decided to be. (Shades of Dr. Pangloss!)

Unfortunately, eating decisions are not purely rational. Eat in a large group, said Ubel, and lingering at lunch could boost your calorie count by 25 percent. Choose the large plate at the buffet table over the small one and bump up calories another 25 percent. Our brains even seek out the bad: give us two identical crackers, but label one as having a more “unhealthy fat,” and we’ll consistently pick it over the healthier-labeled cracker in a taste test.

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The Most Commonsensical And Hopeless Reform Idea Ever

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

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Newt And The Health Wonks: A Tale of Lust And Power

When former House Speaker Newt Gingrich announced his bid for the GOP presidential nomination, I found myself singing a few bars from Night Moves, Bob Seger’s hard-driving tribute to teenage hormones: “I used her, she used me/But neither one cared./We were gettin’ our share.”

No, this isn’t one more commentary on the Georgia Republican’s checkered marital past. I’m referring to a different relationship, the one between Gingrich and the health policy community. A critical component of the climb back to prominence for a man who inspired nearly as much distrust in his own party as in the opposition was proving he could work harmoniously with those holding differing views on an important policy issue — how to reform U.S. health care.

Gingrich succeeded so well that some of the policy recommendations he was touting just a few years ago bear a close resemblance to Obama administration actions that Gingrich now denounces as leading us to “a centralized health care dictatorship.”

The romance between Gingrich and the health wonks, and Gingrich’s makeover as a leader with ideas as much substantive as political, began after the appearance of his 2003 book, Saving Lives & Saving Money. The book gave credibility and visibility to a set of ideas being talked about in the health policy world about using information technology to improve medical care.Continue reading…

ACO Fairy Tale Faces a Rumpelstiltskin Moment

The ACO fairy tale is drawing perilously close to an unhappy ending.

The government’s long-awaited draft regulations on Accountable Care Organizations have brought a dose of ugly reality to a concept that’s always seemed coated with a patina of pixie dust. Unless those regs are substantially changed before the clock strikes Jan. 1, 2012 — the statutory date for ACO implementation — Cinderella’s going to turn back into a scullery maid and the horse-drawn carriage transporting her to the Health System Transformation Ball will be revealed as nothing more than four mice and a pumpkin.

The essence of the ACO concept is using financial incentives to reward doctors and hospitals for redesigning care processes to provide “high quality and efficient service delivery,” in the words of the Patient Protection and Affordable Care Act. As I wrote last fall, ACOs have been the one reform beloved by Republicans and Democrats; doctor groups and insurance companies; policy wonks and profit-seeking capitalists. This unusual unanimity was due in part to a lack of specifics that enabled every stakeholder to gaze upon the ACO and see reflected their very own version of Prince Charming.

Conservatives hail the ACO as marketplace medicine, while liberals focus on organized systems of care replacing fee-for-service chaos. Providers applaud a reform that places them at its center, while health plans know that providers asked to bear financial risk — if an ACO doesn’t measure up, the government won’t pay up — will seek out actuarial experts like them as partners. ACOs also are expected to require the products and services sold by a host of consultants and entrepreneurs.Continue reading…

The Health Reform (Almost) Everyone Loves

Come with me to the land of happy health reform. It is a place where Republicans and Democrats find common ground, a place where physicians, hospitals and health insurers sit together as partners, a place where criticism is respectful, not rancorous. It is the world of Accountable Care Organizations (ACOs).

What are ACOs, and why have they escaped the general onslaught of opprobrium from Obamacare opponents?

The term Accountable Care Organization was originated by Elliott Fisher of the Dartmouth Center for the Evaluative Clinical Sciences, picked up by the Medicare Payment Advisory Commission and then enshrined in Section 3022 of the Patient Protection and Affordable Care Act (otherwise known as health care reform). The language is explicitly designed to use financial incentives to change the health care delivery system.

ACOs are defined less by form than by function. A group of physicians, possibly with a hospital, agrees to manage the full spectrum of care for a defined population of at least 5,000 Medicare beneficiaries for a minimum of three years. If the ACO meets certain targets for quality and cost-effectiveness, it gets to keep part of the savings.

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Health Reform as Theater: Let Me Down Easy

For a Broadway stage, the set is simple and spare – a long, white leather couch, a handful of wooden tables and chairs. No ornamentation is needed; the stories being told on the stage are what command the audience’s attention. Let Me Down Easy is health reform as poignant, funny and gripping theater.

A supermodel compares the high-powered physicians a cosmetics company gets her after she signs a lucrative contract to the doctors she had access to during her working-class childhood. A middle-aged woman emotionally refuses dialysis because of the terrible injuries her daughter sustained while undergoing dialysis when a hospital’s mistake left her covered in blood. And a cancer patient hospitalized with a post-chemotherapy fever describes being told not to take it personally that her chart has been lost: “that happens here quite a bit.”

Every word is true, every story describes a personal struggle with illness, dying and the medical care that sometimes happens in between. Twenty people speak, each in a separately titled vignette, but only one person appears on stage. That’s Anna Deavere Smith, who carefully selects verbatim excerpts from interviews she conducted and then meticulously mimics those interviewees’ body language and speech patterns in a manner so convincing that, in the miracle that is theater, she disappears into her characters. Some are well-known – Lance Armstrong, former Texas Gov. Ann Richards – others are not – a musicologist, a Buddhist monk, a rodeo bullrider.

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Genetic Testing, Fact or Fiction: You Be the Judge

Which of these two events is fact and which is fiction?

  • Organizations representing employers and health plans call for a moratorium on implementation of the Genetic Information Nondiscrimination Act, asserting that the new rules could have a “significant and adverse impact…on wellness and prevention efforts” in the workplace.

  • One of the largest companies in America begins matchmaking its employees based on their genetic compatability, hoping to save on the health insurance bills associated with imperfectly bred children.

Answer: No. 1 is a Dec. 2 press release from the Disease Management Association of America. No. 2 is a description of the Dec. 8 episode of the ABC-TV comedy, “Better Off Ted.”

Coincidence? You be the judge.

GOP to Uninsured: Drop Dead

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

No, that’s not Senate Minority Leader John Boehner, Rush Limbaugh or any of the other usual suspects complaining about the cost of health care reform. Rather, it’s the beginning of an editorial in the Aug. 15, 1949 issue of The New York State Journal of Medicine denouncing attempts to provide every American with health insurance. Sure, 90 percent were uninsured then, versus around 15 percent, today. But what’s amazing is the way the overheated arguments by conservatives have changed hardly at all in six decades, as evidenced by an op-ed in the July 15, 2009 Wall Street Journal entitled “Universal Health Care Isn’t Worth Our Freedom.”

Here’s the August, 1949 New York State Journal:

Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can’t afford to be ill. That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing ­– but which the whole people of the United States would pay for – are also worth nothing.

And here’s Dr. Thomas Szasz from the July 15, 2009 Wall Street Journal:

The idea that every life is infinitely precious and therefore everyone deserves the same kind of optimal medical care is a fine religious sentiment and moral ideal. As political and economic policy, it is vainglorious delusion. Rich and educated people not only receive better goods and services in all areas of life than do poor and uneducated people, they also tend to take better care of themselves and their possessions, which in turn leads to better health….We must stop talking about “health care” as if it were some kind of collective public service, like fire protection, provided equally to everyone who needs it….If we persevere in our quixotic quest for a fetishized medical equality we will sacrifice personal freedom as its price. We will become the voluntary slaves of a “compassionate” government that will provide the same low quality health care to everyone.

Of course, there’s been some progress. Six decades ago, the kind of views expressed by Szasz and the New York Journal represented the medical mainstream. Today, even the most troglodyte are not suggesting the repeal of Medicare and Medicaid.

On the other hand, in those “pre-spin” days so long ago the health-insurance-for-all opponents of the past were forthright about the consequences of their principles for others. Today’s conservative fulminators prefer to forego mentioning the 20,000 preventable deaths each year – about 55 people each and every day – among those without insurance coverage.

The other great difference sixty years has made is the racial and ethnic composition of the uninsured. The uninsured today are disproportionately minority. Nearly one in four (36 percent) are Hispanic, 22 percent are black, 17 percent Asian/Pacific Islanders and just 13 percent white. The impact of those figures is clear. While nearly one third of Texans have no health insurance, the Republicans who dominate its Congressional delegation have shown no particular urgency to address a problem primarily affecting low-income Hispanics. (Fifty-eight 58 percent of the uninsured in the state are Hispanic, according to Kaiser Family Foundation figures.)

It’s important to remember that none of the Republican presidential candidates in either the primary or general election presented a serious plan to cover all the uninsured, nor have any of the Congressional GOP critics of Obama’s plan done so. In other words, the difference between the Democrats and the Republicans on universal access to health care, then, is not a difference on government should help accomplish this goal but whether the goal itself is worth pursuing.

Put differently, for those Americans who can’t afford medical care (or are afraid that they won’t be able to in the future), the GOP has a clear reply: drop dead.

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Fantasy League Baseball — Beltway Series Edition

Millenson_122k_3Bob Laszewski’s Health Care Affordability Model has the same connection to the reality of the current  battle over health care reform as a Fantasy Baseball League does to the actual outcome of a major league baseball game; i.e., none.

 Actually, while those who play Fantasy Baseball – might we call them “baseball wonks”? – are affected by what happens in the real world to the players they have selected, they have no illusions of reciprocity. Laszewski is a brilliant analyst whose examination of the various political proposals for health-care reform have become a “must-read.” But in making his own proposal, Laszewski, a strategy consultant based in Washington, has managed to completely ignore the fact that reform is an intensely political process.

 “The Health Care Affordability Model…could be attached to virtually any health care reform plan now on the table,” he writes.

 No, it couldn’t. Just like managing a Fantasy Baseball team has no connection to managing real major league players. Given Laszewski’s timing, his proposal is somewhere between almost irrelevant and completely so. Which is not to say his ideas are wrong.

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