Tag: Policy

Michael Porter–seduced, converted, or bludgeoned into accepting reality?

6a00d8341c909d53ef0105371fd47b970b-320wi What a difference a few years makes. Michael Porter is the Harvard Business School prof who charged into health care a few years back. He (with Elizabeth Teisberg) wrote a book called Redefining Health Care which suggested how all kinds of changes on the delivery side of health care would solve all of our problems. Those changes were not exactly secrets to people who, say, read Michael Millenson’s Demanding Medical Excellence—a much better book written ten years earlier which explained why radical change on the delivery system side wasn’t going to happen. The answer?

It’s the Incentives, stupid.

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I’m not sure that’s how Uwe meant it!

The AP has a puff piece on the greatness of Karen Ignagni. Well greatness if greatness is defined as doing anything it takes to screw the nation on behalf of her organization’s members, all the while telling bold face lies about their activities. But the lies of Karen Ignagni have been well documented here on THCB and we don’t need to rehash them now.

But then the AP reporter Erica Werner quotes Uwe Reinhardt and has this somewhat remarkable passage:

"Whatever AHIP pays her, it's not enough. She's unbelievably effective," said Princeton economist Uwe Reinhardt. "It's just amazing what she's achieved for them against all odds." Ignagni's total compensation, according to AHIP's most recent filing from 2007, was $1.58 million, which includes $700,000 in base salary, $370,000 in deferred compensation and a bonus. Ignagni won't say how many hours a week she works. The number's so high it's embarrassing, she said.

Among successes cited by Reinhardt and others is helping persuade the Bush administration to develop private insurance plans within Medicare that are producing unexpectedly high payments for private insurers. When Congress was considering expanding a children's health insurance program in 2007 by taking money from the private Medicare Advantage plans, Ignagni worked successfully to stop it. Those private plans are being targeted again by Obama, who wants to squeeze them to pay for his health care agenda. Ignagni's industry group is organizing older people to defend the plans.

There’s lots of more puffery about how she’s good at building consensus among the diverse interests in her group. My take on that is “we’ll see”.

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Thomas Kuhn, Health Care Reform and Vascular Disease

The puzzle of improving care and reducing costs in American medicine and in vascular conditions (that is, diseases associated with blood vessel metabolism) in particular – these are responsible for 60 percent of all cost – has been in part due to the nature of medicine itself.  Physicians are at their core scientists. Our undergraduate degrees are in the scientific disciplines of biology, chemistry, physics. We have been educated in the culture of science and that is the environment in which we practice.

Thomas Kuhn’s The Structure of Scientific Revolutions perfectly describes a central problem in cardiovascular diseases.  A scientific community cannot practice without a set of core beliefs. These central constructs are, in Kuhn’s terms, the foundation of the “educational initiation that prepares and licenses the student for professional practice.” The student’s instruction is “rigorous and rigid,” with the purpose of ensuring that these beliefs are firmly fixed in the student’s mind.

Scientists go to great lengths to defend the idea that they know what the world is like. It should come as no surprise then that “normal science,” – that is, the framework to explain the world used by the scientists who lead the current paradigm – will often suppress novelties that undermine its foundations.

So research often is not about discovering the unknown, but rather “a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education.” A generally-accepted paradigm, essential to effective scientific investigation, requires “some implicit body of intertwined theoretical and methodological belief that permits selection, evaluation and criticism.” That paradigm, in turn, forms the basis of a new profession or specialty, like Interventional Cardiology, and from this follows the establishment of journals, societies, and a special place in the medical academic structure.  The articles in those journals are intended for professional colleagues who share the the field’s knowledge and who are the only ones capable of fully understanding them.

A shift in the accepted scientific construct occurs when research aimed at further developing that formulation of the evidence runs into an anomaly — a fact that does not fit the paradigm and cannot be explained away. When anomalies pop up, they typically are not welcome and may be ignored. The current paradigm’s scientists may make little or no effort to formulate a new theory to explain the phenomenon. They are also likely to be intolerant of practitioners who try to do so.

All the same, the discovery of anomaly is the stimulus that leads to a new paradigm. The failure of  existing beliefs and rules is the necessary but insufficient platform for the development of new scientific and practice structure.

The leaders of an entrenched paradigm strongly resist alternate systems of science and practice. Only in  crisis can that resistance be overcome. No better example of this can be found than the current situation in the treatment of cardiovascular and arterial disease.


The fixed blockage is the dominant paradigm today for both the science and practice of cardiovascular and arterial disease management. In other words, it is viewed as a plumbing problem. This paradigm has persisted because it made so much sense.

Angina is a historical diagnosis – particularly in a man.  Just talk to the patient and you can make the diagnosis. If a man walks and gets chest pain that is relieved by rest, he has angina. Almost all of those men have a blockage of 70% or greater.

If the cardiologist does a catheterization he will demonstrate the blockage.  If he opens the blockage with a stent the pain will go away.  But many men with angina go on to have heart attacks – it is high risk.  So it is no surprise that blockage became the dominant scientific paradigm. To this day, virtually the entirety of the science, practice, and financing are organized around this idea: Heart attacks are caused by a progressive blockage. If we open that blockage before it becomes complete, we will save the patient.

Now the anomaly. In 1988, WC Little and his colleagues at Wake Forest performed a study “to help determine if coronary angiography can predict the site of a future coronary occlusion.” If the plumbing model were correct and a progressive blockage of the artery caused myocardial infarction, the findings on coronary angiography should predict the site of heart attack. It did not.

Little and his colleagues studied 42 consecutive patient records of patients who had had coronary angiography before and up to a month after having a heart attack. In 19 of 29 (66%) patients, the artery that occluded subsequently had less than a 50% occlusion on the first angiogram. In 28 of 29 (97%) the stenosis (or narrowing of the vessel) was less than 70%, even though it takes a stenosis of 70% or greater to justify angioplasty with stenting.

Little concluded

“Because it was difficult to predict the site of subsequent occlusion in our patients from the initial coronary angiogram, coronary bypass surgery or angioplasty appropriately directed only at the angiographically significant lesions initially present in almost all of our patients would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”

And, in keeping with Kuhn’s description of the scientific revolution, the best arterial disease scientists quickly developed a new paradigm that provides a much better explanation of the mechanism of heart attack and other vascular events. Within 7 years of the first anomaly, Erling Falk, Prediman K Shah and Valentin Fuster, leading academic cardiologists, summarized four studies that came to the same conclusion as Little. Only 14% of heart attacks occur in an artery that was 70% blocked on the previous catheterization. Only 14% of heart attacks occurred in an artery with enough obstruction to cause angina and justify bypass surgery or stenting.  Falk and his colleagues described the new paradigm very simply:

“plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”

Peter Libby is Chief of Cardiology at Boston’s Brigham and Women’s Hospital, one of Harvard’s teaching hospitals. One of the world’s foremost authorities on the science of heart attack and plaque rupture, he quite literally “wrote the book” on the topic. In the volume of Harrison’s Principles of Internal Medicine, the standard reference text for the discipline, that sits on my desk, Peter Libby wrote the chapter entitled The Pathogenesis of Atherosclerosis.

In 1995, the same year as the Falk article, Libby wrote a piece called “The Molecular Basis of the Acute Coronary Syndromes.”

“Bypass surgery or transluminal angioplasty (dilation of the artery and then, propping it open with stents) provide rational and often effective therapies for these fixed, high-grade stenoses (blockages).  However, these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot).  It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”

In other words, heart attack is not caused by a gradual narrowing of the artery, but rather is the result of sudden cholesterol plaque rupture with subsequent clot formation, which blocks off the artery and cuts off blood flow.

Today, 14 years later, we can dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose.  We can prevent clot formation with aspirin and other medications.

The scientific revolution in vascular disease is 20 years old and the new paradigm firmly in place and supported by the very best vascular scientists. Still, the practice paradigm persists as if the science never changed.

Just last year, I heard a brilliant talk by Valentin Fuster, one of the co-authors on the Falk article. Afterward I asked him what it would take to move the practice paradigm forward. He responded that it would take the time required to replace current practitioners wi
th the next generation.

Can we afford to wait for that?  Several years ago, I heard Dr Libby speak at a national meeting of the American Society of Hypertension. I later asked him, “Dr Libby, I read your article from 1995, saying that bypass and stenting do not prevent heart attack, do you still hold that view.”  He became very animated and enthusiastic and said he was convinced that the new science was valid and required action to move it forward.

The science has become irrefutable.  Yet the defenders of the old science still carry the day.  I fear that medical scientists will not move this forward and it will require changes in payment and support for research coming from outside the professional community to bring the latest science to patients.

We have to recognize the suppression of anomalies and new paradigms in medicine. Only then can we develop mechanisms that can bring the latest evidence-based science to patients.

Bill Bestermann is Medical Director, Integrated Health Services at Holston Medical Group in Kingsport, TN.

How to Waste a Boatload of ARRA Money

Cindy on BusI want to take a moment to make sure we are all on the same page here with the business of health care  reform.  This is inanely simple.  When it comes to health care, keep doing things the same way.  It’s a proven business model. Here are a few specific pointers.1) Don’t Involve ConsumersThis is really critical.  Do *not* ask consumers what they want.  Whatever you do, don’t ask consumers to define “meaningful use.”  These kinds of rhetorical debates are best left to academics and bureaucrats inside the beltway. Every time a consumer mentions anything resembling meaningful use or a “personal” health record, change the subject immediately.2) Act Like Privacy Issues are InsurmountableThe possibilities here are endless.  The more you can distract consumers with potential privacy issues, the less they will pay attention to the ways in which they would benefit from having true ownership of their health care data.

3) Don’t Learn from Other IndustriesDon’t bother reading that book by Clay Christenson.  He has spent a decade studying the inefficiencies of the health care system.  Inefficient by whose standards?  Let the academics put their two cents in when it comes to meaningful use, but don’t listen to any of that Harvard B-school innovation nonsense.4) Act Like Open Source Doesn’t ExistFortunately, most people have long forgotten that once upon a time, software was free and/or inexpensive.  They continue to blindly support proprietary software, even during a prolonged recession.  They even purchase new computers to run this bulky, expensive software!This ties into the next point. 5) Think Short TermThe time to think through any major conceptual problems is not now.  Come up with brilliant, yet strangely expensive health care solutions (remember, they must be proprietary).  Don’t worry about long term sustainability or stupid things like sharing your source code.  Having proprietary solutions is exactly the leverage you need to maintain your involvement in perpetuating, I mean solving, the problem.  This is advice you can (both literally and figuratively) take to the bank.Oh, yeah, speaking of the bank, by the time tax payers realize what you’ve done, you will have already deposited your bonus check and had a fabulous spa treatment.

Cindy Throop is a University of Michigan-trained social science researcher specializing in social policy and evaluation.  She is one of the few social workers who can program in SAS, SPSS, SQL, VBA, and Perl.  She provides research, data, and project management expertise to projects on various topics, including social welfare, education, and health.

Disgusting, and another reason why marriage needs to be re-defined

Tara Parker-Pope reveals two cases where discrimination kept a partner, and in one case the dying woman’s children, away from their loved one while they were dying in hospital.

One hospital involved is Jackson Memorial in Miami, a massive recipient of Federal dollars. In 1965 then un-integrated hospitals in the south were forced by the Federal government to take black patients as part of the new Medicare program. It’s high time that an executive order was made by Obama that hospitals receiving Federal dollars immediately change their visitation policies in this respect.

But beyond that, those bigots (including the ones who have commented on THCB) who continue to maintain that not changing the legal definition of marriage doesn’t hurt anyone should consider the stories of the people Tara reports about, and they should feel very guilty.

Connecting finance to coverage

Repeating his message that Health Costs Are the Real Deficit Threat OMB Director Peter Orszag goes into the not exactly friendly territory of the WSJ Opinion pages and explains that practice variation is unnecessary and wasteful, comparative effectiveness research is a good idea. and that changing financial incentives for providers is necessary if we are ever to get health care costs under control.

The question is, how much of this gets included in the woffling coming out of Sen Max Baucus’ Senate Finance Committee? Here’s the press release on the options they’re considering. It’s a little like Stalin in 1930 saying, ‘the people are starving, we may collectivize the Kulaks, or we may rent them their farms back, or we may do nothing, or all of the above”. OK you may think I’m kidding but they give four different options for what a public plan may look like, six different approaches to small group and individual market reform (none of which deal with the smallest employers), and nothing about Orzsag’s concept of “changing financial incentives for providers”. Apparently that’s unrelated to insurance reform. (Yes yes I know they’ve floated some trial balloons about that too….)

What worries me is that because of the downturn and Orszag shining the light on the finance issue, we may have the chance to both fix coverage and finance. But I don’t see this all happening together.

So far I haven’t seen anything to change my mind about what’s going to come out of this process. So to bore all of you still reading I’m going to repeat what I said when I reviewed Tom Daschle’s (remember him?) book Critical.

So my guess is that the Federal Health Board, if it gets established, will get defanged by lobbyists immediately. The consequence of that is that the mish-mash of an “expand what we got now” system will cover a few more people at a lot more cost (as has been the Massachusetts experience). That’s OK because suddenly we’re rich (or at least suddenly the government is pretending it is!). But in a few years the stimulus will end and health care costs will have kept going up. Then we’ll realize that due to more cuts in Medicaid & subsidies for the working poor, and continued cream skimming and bad behavior by private-sector health plans, enough people have fallen through the cracks of the incremental expansion that we’ll be back where we are today again.

CODA: Click here to have some fun as to what happened when Baucus lined up 13 Democratic economists to talk about health care to his Committee and somehow couldn’t find even one who was in favor of single payer…

An Open Letter to the New National Coordinator for Health IT: Part 3 — Certification As The Elephant in Health IT’s Living Room

6a00d8341c909d53ef01157012476e970b-pi In the first and second parts of this series we talked about how and why there is no universal definition for the term “EHR.” Instead there is a legitimate, growing debate about the features and functions that “EHR technologies” should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should “separate the data from the applications.”

We also argued that there is much to learn from development platforms, recently and in the distant past, that have used standards to open the aperture of innovation. The best of these standards have reflected the experience of what works rather than specifying how to make it work. Defining the standards for data, devices, and network technologies too restrictively could choke off innovation, rendering HITECH’s offerings whose expense and complexity are a barrier to, rather than an incentive for, adoption by physicians. Incoming National Coordinator for HIT David Blumenthal, MD seems to have been considering just this concern when he recently wrote:“… [M]any certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.”

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Of Healthcare and Toilets

Tobias Gilk “Any system produces exactly the results it was designed to produce,” or so goes the saying. If we don’t like the results we get, we need to re-examine the system and not simply individual inputs.

In the US, healthcare’s systemic complexity has gone from that of a grandfather clock to nuclear reactor over the course of the past 100 years. If we really wish to improve the results of US healthcare, we need to look at the totality of the system, the multitude of inputs and outputs.

EMR’s, reimbursement rates, pre-authorizations, universal coverage and each of the many hot-button topics swirling around the question of healthcare reform are all important inputs that effect quality, cost, access, but I’m very much a hands-on person and I want to know what these have to do with the physical points of distribution of healthcare… our doctors’ offices and hospitals?

We know that a hammer sees every problem as a nail. And I concede that my predisposition as a recovering architect is to see the problems inherent in the physical instruments of our healthcare delivery… namely hospitals.

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Where’s THCB’s share of the money? Or does Stuart Browning feel left out?

My lefty friends at emailed me (and a few million others) appalled that Rick Scott’s group is going to be spending $1 million running ads attacking the as yet officially non-existent Baucus/Daschle/deParle/Obama health plan. Now that’s not exactly a surprise. Rick Scott has been on the offensive for a while now and in the spirit of inclusiveness (or the more cynical among you might say, to start a fight in an empty house) THCB ran his op-ed a while back. Frankly it was pretty tough to figure out what he was “for” but it’s clear what he’s against—the evils of Canada and the UK.

Yesterday I had a little fun teasing some Norwegians over here to learn about the US health care system. I asked them what they wanted to learn about, and one of them said “what about the 48 million uninsured”. I told her that Americans were a kind and generous people, and that there couldn’t possibly be anyone here uninsured or suffering because of it, and obviously the two Michael’s at Cato and the nutjob prof at Harvard prove me right about uninsurance being a) voluntary and b) the fault of three Medicaid clerks in New York state who forgot to print the enrollment forms in Spanish. OK, OK, I changed my tune a little a few seconds later.

But that remains basically the screed of the Canada bashers. They say that those evil Stalinists in the UK and Canada are the same (even though they’re not), and no one gets any care. Whereas here it’s all sweetness light, teddy bears, puppies and all the MRIs you can eat.

However, I am beginning to tentatively that the lack of mainstream industry support for Rick Scott signals a couple of things—besides the fact that the mainstream is somewhat nervous of being led by an unconvicted fraudster man whose company settled with the government for $1.7 billion after it fired him.

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An Open Letter to the New National Coordinator for Health IT – Untying HITECH’s Gordian Knot: Part 1

KibbeB&WjpgCongratulations to David Blumenthal on being named National Coordinator for Health Information  Technology (ONCHIT). Dr. Blumenthal will be the person most responsible for the rules and distribution of the American Recovery and Reinvestment Act’s (ARRA) nearly $20 billion allocation, referred to as HITECH, designated to support physician and hospital adoption of health information technologies that can improve care.

The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, “Stimulating the Adoption of Health Information Technology,” is a concise, clear and honest appraisal of two of these challenges, namely how to interpret and act upon the key terms used in the legislation, “meaningful use” and “certified EHR technology.” Dr. Blumenthal gets to the heart of the matter by identifying the tasks on which the National Coordinator’s success will most depend, and which will foster the greatest controversy.

The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.

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