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POLICY: How dumb is the NY Times?

Like a dog licking an open sore, the  NY Times again returns to the "we spend so much on health care because it’s worth it" meme in a ridiculous article called The Choice: A Longer Life or More Stuff. (This post was about a different NY Times author’s stupid article on the same subject last month). They then print a bunch of reader responses, sadly few of which point out the fact that compared to countries who spend less money we’re not getting "longer life" (although the first one does).

But none of them point out the simple truth. We spend that much because the system has been politically rigged so that it’s virtually impossible not to. There is no causal connection between the vague desire for increased life expectancy on behalf of the public, and the increase in health care system spending. But there is a huge causal connection between the desire for greater health care system revenue on behalf of the system stakeholders and the increase in health care spending– because we have a funding system set up on their behalf. Has the NY Times not heard of, say, Medicare Part D? Have they not heard of 30 years of Wennberg’s Dartmouth works which proves that high cost care has bugger-all to do with improved outcomes? This is like saying we need 5,000 nuclear warheads or a brand new attack fighter 15 years after the end of the cold war, or that the drug war is effective. It’s patently not because we need those things, but it’s because there are strong interests that have gotten them funded!

Why can the NY Times, which does occasionally notice the rape and pillage of the ecoonomy by the health care system (though not as well as the WSJ does), not leave this open sore alone? Perhaps Judy Miller has been reassigned to the health beat and is ghost writing all their stuff, being fed lines by the health care equivalent of the Iraqi National Congress. What other explanation makes sense?

 

 

QUALITY/POLICY: Futurist’s forecast from Clem Bezold

Clem Bezold from Institute for Alternative Futures (kind of the alternative IFTF) gave an overview of the conference and an optimistic 2016 forecast for the availability of broadband to the home, better knowledge and personalized tools that will work on that information. Then he gets a little more controversial, including personal values, need for universal coverage, end of life care in context, etc — all as part of care in 2016

His main talk is about accelerating Disparity Reducing Advances project—wants to accelerate the technologies and process that reduce the social disparities in health care. They are not looking at the bigger picture of employment, education, etc, (consciously) and its impact on health, but they think that they can make a difference in the health care provision and tech part. They’re trying to pick their targets. And the first one is:

—Prevent obesity in poor populations. That leads to different levels of action in diff government and social programs. but we need to change the social environment, including getting the right foods into the right neighborhoods, as well as doing the health care screening and pre-diabetes initiatives. So there are a whole variety of factors you;d get to for any diseases, and information therapy is a big part.

Some things they’re trying—working with cell phones (LG has launched a diabetes phone this month which has a built in test strip reader. Also looking at biomonitoring activity, all connected to cell phones infrastructure. But needs to be connected to services. There are proposals to say that spectrum should not be auctioned off, but instead should be free (internet telephony over free wiMax?). That will be all added to patient and care giver “navigation”.

His forecast for monitoring. By 2008 standards for biomonitoring; by 2012 reimbursement has changed so it gets pay for; by 2016 common in us for monitoring the chronically ill and elderly. My feelings that this is about right, but it’ll require a whole hell of a lot of changes in the system…and of course there are huge infrastructure issues for the lower income providers (tech access, language, etc) which Clem spelled out clearly (and far too quickly to note down easily!)

Clem is an “aspirational” futurist who’s trying to change the future as much as explain it. At IFTF we were “analytical” futurists, and we derided the aspirational guys as the “personal helicopters by the year 2000” school of futurist — but his talk was really interesting, and frankly alot of analytical futurism is by definition wrong. So hopefully Clem provoked some big goals that we should all be going after.

I asked him about the norms of advertising for food and obesity—he thinks policy things can be done. And also about the system change required for home monitoring? How can the system change? He thinks that health care will be redesigned the hard way, otherwise it’s a perfect storm. It’ll get worse before it gets better. How do you get the patients and care-givers in the right place within the system. We will re-torque our use of health care providers to make that change.

Josh Seidman put up the Ghandi mantra “First they ignore you, then they laugh at you, then they fight you, then you win.” I think Ix is still being ignored, but soon it’ll be heading to the “fighting” part—and that is when it’ll get brutal.

Meanwhile in a moment of Ghandi zen, here’s a photo of a balloon over the canyons this morning

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QUALITY/TECH: Intel’s Dishman wants a proactive health system

He’s been running the R&D for Intel’s health group, which basically means ethnographic research about over 500 households. They largely focused on using “caring machines” to monitor and support the care of the elderly in home, and the chronically ill. In his view care needs to be pro-active, needs to be personalized, connected (across the care network), continuous across conditions, and bionic. His other view beyond Intel is CAST has 500 companies doing major demo days like the White house conference on aging. The commission for aging in place technologies…

The current hospital system is what he calls “mainframe technology” — as people get old, that’s not going to scale. the same metaphor is true for health care—the power of the mainframe goes to the PC to the cell phone. And of course going from point intervention to continuous monitoring.

Sidebar: cool to hear a business executive telling his audience to read Michel Foucault

Dishman showed a prototype PHR/life management system that connects, which includes daily schedule, a “presence lamp” showing when other care-givers, family are in their houses, via sensor network. It includes a “social health” world which shows how close family members are to the person at the center, because it measures by phone sensors, and activity sensors (the more contact the closer people get to the middle). See the photo below for a poor representation of what the hell he’s talking about) This has been called “making the invisible visible”.

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They’ve added photos of people calling and social network diagrams on the phone for those with memory loss (caller ID on steroids)

Intel also has a Parkinsons assessment box, which integrates the clinical tests done for parkinsons (moving pegs on a board), tracks motor skills, tremors etc….and then will titrate the drugs best on how people are doing.

Interesting stuff…but then he notes we’re working out how to pay for all this stuff……

BLOGS: Starring moi!

Tomorrow I am on two unrelated panels on the same topic!

Firs at 8 am PST at Jack Morton Worldwide (PR agency) (at 560 Pacific Ave San Francisco, CA)  there is a panel on Engaging Blogs and New Media from the PRSA Health Academy. Dimitry will be the other blogger there along with Amy Hughes from Cisco and Dr. Harold Itskovitz

Then immediately afterwards Bulldog reporter is having an online audio conference called Advanced Secrets of Pitching Blogs: Influential Online Journalists Reveal How to Tap the Blogosphere to Protect and Promote Your Brand Online. On that one will be real blog stars including Tom Foremski, Eric Alterman & Jeremy Pepper. I hope I don’t look too foolish in their company!

Click on the links for details.

TECH/QUALITY: More quick hits from Ix conference

Deborah Bell—Runs ovarian cancer listserv and became an in-depth patient

Alan Greene, the pediatrician who runs DrGreene.com, and gets 50 million hits a month from 2 million unique users—Money quote for doctors online and off – “You have to get to the spot where you are OK that you patient knows more than you do.”  He rewrote the Hippocratic oath because it said that physicians should NOT share information with patients!  But doctors should still take a stand and tell patients what they really think.

Don Kemper, Healthwise—Infrastructure change saves lives for average people. Water quality; seatbelts in carsthey worked for the 20th century. What about the new century? How about message systems to tell you about immunization for kids? Information to cut out unnecessary surgery? Medication adherence protocols and information for everyone?  Personalized wellness, prevention and screening for everyone? An appreciative approach to the end of life? We need to change the infrastructure so that the average person cannot avoid the Ix infrastructure!

TECH: MedEncentive–a “commonsense” P4P program

MedEncentive’s system allows doc and patient to declare their compliance and then agree to let the other patient confirm the compliance. And their study shows that it works. Here’s the press release on the study and here’s the study in full. (BTW Here’s their agreement with Healthwise).

Jeff Greene the CEO of MedEncentive thinks that he’s got around all the issues that block the intro to P4P (more work, no more money, transparent info they don’t trust, etc). He doesn’t approve of the stratification. “We’ve got to make the bad docs better and the good docs faster”. He thinks that we don’t need to beat up on docs, when the real increases are going to pharma and hospitals.

P4P works if docs accept it, patients are involved, and there is a positive ROI.

How do they do it? Both docs and patients get rewarded immediately when do they something good.  Here’s how it works from their release:

Physicians were compensated for accessing MedEncentive’s website to declare compliance to or provide a reason for deviation from evidence-based medicine guidelines and for prescribing information to their patients for each office visit. Patients were instructed to go online to receive the prescribed information about their diagnosis and treatment and to confirm they followed the doctor’s advice in exchange for reimbursement of their office visit co-pay. Both parties were also asked to confirm the others declarations, thus creating a powerful interactive check and balance.

MedEncentive gets a PMPM payment for their service. They authenticate that EBM was used, and when they authenticate that EBM and IX were used, then they pay a spiff to the docs (20% more than standard fee) and they rebate the co-pays to the patients. And it makes overall costs go down (as it reduces hospital and pharma costs).

There’s an ability to deviate off the guideline if they have a good reason, and then they show the patient why later and let the patient comment. (The docs will soon be asked about patient compliance). The patients used computers to access the IX, and the customer (a municipality) set up computers for retirees. The consumers get $30 for reading the Ix material (which is a study and a questionnaire—like online traffic school) and then they ask them to rate the doctor. They aggregate the patients rating per doc and show them the overall score (not individual patients rating).

The docs say that it improves their productivity, as their patients are more informed. And chronically ill patients don’t want their patients to think they’re not compliant.

Jeff thinks that HMOs failed because we put all the incentives on the provider side. Now HSAs are going to put it all on the patient side. He thinks that responsibility needs to be shared and they’re calling it Interactive Accountability.

Results of the study—In Duncan OK, town of 22,000. Set it up for 60 days. Patients told, “ask doc for the info therapy Ix and get money back”, and they hand out Ix pads for docs. They then take the claims data from the employer TPA, and analyze what happened. And of course almost all the savings came from a big reduction in hospital costs. There was also a big reduction in radiology costs (that’s the only specialty that saw a reduction)! The city saw a reduction in overall costs—the city saw a reduction of 11.5% from baseline year to intervention year.

 

 

TECH: More on Tech from Ix

Holly Miller runs Cleveland Clinic’s MyChart. Cleveland Clinic has rolled out Epic EMR to its main campus, all its primary care clinics and about 25% of its affiliated specialists. Also rolling it out to community physicians who admit to its affiliated hospitals.

MyChart is a complex combination of a view a) into the Epic system, plus b) to their own editorial information plus c) into WebMD content (to which they supply content). The information has been empowering to patients. They can see the visit note, which includes a patient instruction function. The patient can get information about all kinds of stuff based on their own test results, connected to those results, including what the test is, what it means, and what the normal range is (plus whatever note the doctor wants to add). She has one patient who read up on diabetes in conjunction with a physicians visit, realized that she was on the verge of becoming morbidly obese, and read up on how to stop it. 70% of messages sent out are opened in the first week.

They are now starting to have information from diabetics input straight into the system, with immediate feedback on results, including surveys, information, etc, and what to do if the measure is way out of line (It also has histories, etc,etc). They’ve been running the study for a while. Only about 25% are looking at the information links they’re sent, but more are looking at lab results.

They’re pretty serious about this, and have a person who’s job it is to monitor web behavior both in terms of customer service (following up on appt requests within a certain time) and trying to figure out how to move and improve patient online behavior. Keep watching this space….with PAMF, Kaiser and Group Health of Puget Sound, these guys are leaders in the provider-based PHR world.

POLICY: The Uncertain Future of Public Retiree Health Coverage

Brian Klepper has been warning about this for a while. Public agencies have much better benefits for their employees than their private equivalents. And they don’t account for those future costs. There is a FASB106 moment coming up—it was FASB106 that inspired private corporations to push managed care in the 1990s by forcing them to put their future health care liabilities on their balance sheets. Same thing is about to happen to government agencies, hence the new CHCF focus on The Uncertain Future of Public Retiree Health Coverage.

“These accounting changes will illuminate the significant and growing impact of retiree coverage on many public agency budgets,” said Marian Mulkey, M.P.P., M.P.H., senior program officer at the California HealthCare Foundation. “Difficult decisions about spending priorities will follow.”“By confronting this issue head-on and weighing options, elected officials, administrators, unions, and other decision-makers can begin to identify remedies to this complex problem,” said Dr. Smith.

In other words the brown stuff is about to fly through the air to hit the whirly thing. 

QUALITY: DM on Medicare Health Support, and a nice award

Next up at the Ix conference, Medicare Health Support got three cheerleaders telling us that they’re doing very, very well (Sandy Foote ex CMS, George Bennet from Health Dialog, Michael Montijo from American Healthways. There;s lots and lots of details about how to do this, and there are lots of problems to be overcome. But it works. I wont go into the details as I’ve written plenty about it a while back. And my sense is that the lack of DM is so apparent in the wider health system that basically any intervention which concentrates on educating and informing people about their health works.

I want to know whether it will work when we look to crank down beyond the 5% savings that Medicare Health Support committed to making today. Usually the rule is that Medicare overpays the private sector for what it does. But perhaps we’ll never find out.

Meanwhile, Ted Eytan, who’s the MD who runs Group Health Cooperative in Seattle’s Informatics group just won the first annual award for really making a big difference in information therapy (not sure what the award really is called but that’s what it’s about). No question that GHC is a leader, and kudos to Ted for making it so! (Ted is also the sponsor of a secret blog which will appeal to you process types)

POLICY/HOSPITALS: UNC relents from going after the house

Jerry Ansley has had a pretty tough time, catching encephalitis, going to the hospital alot, and losing his life savings because whatever level of health insurance he had wasn’t enough. The good news is that after lots of pressure Univ of North Carolina Medical Center has relented on its legal claim to go after his house—all he had left. Nice, eh.

This is the kind of horror story that we’re going to see lots and lots more of in the coming years—especially next year when Jonathan Cohn is going to become a big media star after his sifting through the appalling underbelly of the insurance market, or the lack of it, appears in print.

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