I’ve never heard of this little practice management company Dr Notes, but thewhole scam seems quite fun. This is why it’s good that there are finally real companies that doctors can deal with.
Above the Fold
INDUSTRY: Health Care Mergers up
Jonathan Cohn is very excited that health care mergers are up strongly in the third quarter. I suspect its a blip, as Wellpoint’s got no one left to buy, and who’d want Merck in its present state? But who knows what excites the Volvo driving frappuchino drinking liberal intellectual, these days. (Hint, conspiracy theories around Medicare Part D and health care as the "new defense" might be the answer).
Meanwhile I’ll have more on the PHR later, as I’ve had my knuckles rapped by someone who knows more than me about consumer surveys….
TECH: PHRs, EMRs and pretty much useless surveys
Because there was a conference Tuesday on Personal Health Records sponsored by RWJ and Markle, there were two surveys out yesterday about consumers and their interest in/love for/need for/ likelihood to buy into electronic medical records. The Markle Foundation, by the way, is one of the (frankly too) many organizations trying to push EMRs and PHRs on the unsuspecting American public — other than the public is now starting to suspect a little bit. In fact my girlfriend showed me an article in the Southwest Airlines magazine about the national health information initiative which I suspect wouldn’t have happened five years ago.
Markle’s survey suggests that 71% of Americans are in favor of EMRs, although in their release and in this article there are suggestions that privacy, confidentiality, motherhood, baseball, cute puppies and apple pie will have to be provided before people will actually use them. David Lansky is not a dumb guy but the seven principles are little too obvious and somewhat ignore how information technology actually gets dispersed and used (forget higher moral callings, and think porn and Baywatch). It’s yet another necessary but nowhere near sufficient list that was clearly designed by a committee, and I’m not too sure that their worthy effort will help that much.
But at least they have some decent numbers in their survey, suggesting that 60% of Americans want a secure online PHR and only 19% wouldn’t use one under any circumstances. In fact more say they would use one (68%) to order prescriptions than would support the creation of PHRs in the first place. I assume the extra 8% are on the fence but would use it if it was there — or maybe it’s just an example of Americans being unable to keep their survey answers logical from one question to the next.
Meanwhile Manhattan Research continues to put out absolutely minimal snippets of information in its press releases. (I know I used to work for Harris but by comparison their releases and newsletters are treasure troves). Today’s release is that 15% of Americans (adults I assume, as they claim that equals exactly 29.8m people and there are about 300m Americans) are "on board" with an unspecified level of "interest" or "demand" in a PHR. Beyond the fluff there’s not much more information in their release other than they think that there are "7.6 million consumers actively emailing with their physicians". Working backwards from their other numbers this that means about 4% of American adults are emailing their doctors. Whether that counts me I don’t know. I emailed my doc using the RelayHealth system, and 6 months later his office emailed me back telling me that my application to email him was rejected.
So given that 15% is a lot less than 60%, Manhattan’s numbers are way lower than Markle’s and also way lower than these numbers from Harris last year regarding interest in using personal health records (although Harris found that almost no one was using an electronic PHR). In addition Manhattan’s email numbers are not far from the numbers I was getting about patient-to-doctor email use back in 1999–even though use of email generally has grown dramatically since then. Now, I’m not so sure Manhattan’s wrong. I don’t know — although I’ve asked and hopefully they’ll tell me — what their exact questions are, and the difference in the results is probably in the phrasing. And anyway all the way through the 1990s their predecessor organization, CyberDialogue, consistently under-counted the number of adults on the Internet, at least compared to Harris and Pew. But the evidence of successful PHR companies (or rather the lack of them) suggests that this type of PHR or patient-provider communication is minimal.
But the point here is not which survey company has got it closer to the truth. The point is that the growth of the PHR has almost bugger-all to do with interest from the consumer. If you’d asked consumers about their interest in online banking, online poker or online porn back in 1993, their answers would have been equally irrelevant. Consumers got online because they got used to it at university and work, and then at home it became available cheap (thanks AOL) and most of all because of email. Once they understood email, and once Tim Berners-Lee (from CERN not Cerner, as HISTalk hilariously pointed out) invented the Web, then all those other applications took off because someone supplied them and aggressively marketed them (OK, perhaps the porn didn’t require that much marketing!).
The problem with PHRs and EMRs is that the people who could or ought to do the supplying (the people with the patients’ data from which to supply the information) either didn’t do it for a combination of business reasons and technological incompetence (health plans) or because they didn’t have the data in a usable format (hospitals and doctors). And no one had any interest in marketing it, other than the standalone eHelath companies who had no links to the local providers and services, or personalized data, that the patients wanted.
To be frank, we’re not a whole lot further on, although we may be getting somewhere finally on the health plan side if WebMD finally gets Empire and Wellpoint off the dime. But as with the ridiculous survey that Accenture put out a few months back, asking consumers what they want to do and would pay for is pretty useless. They’ll do it if it’s marketed well to them, if it fits into their life "workflow", and if it’s useful and/or entertaining. That’s why Google searches on health topics are off the charts and why no one emails their doctor (even if Syd at Medpundit apparently thinks its her patients’ fault)
But the key issue is that we’re still a long way from many doctors having the data in a usable format to supply to their patients. Unless of course we all move to Seattle and sign up for Group Health. Harris reported in a WSJ survey just last week that while 79% of the public approve of the idea of the EMR (again near Markle’s numbers) only about 16% of the public had actually seen a doctor ever use one in real life. And if you think that the system is magically going to immediately respond to the consumer’s newly discovered desire to get their own health information every place they need it when they want it, well go back and read MrHISTalk’s excellent article on whether one health care organization can actually share basic allergy information within its own IT systems. then extrapolate to whether they can then provide that information back to consumers in double quick time. Hint, the answer is "extremely unlikely".
CODA: By the way, Esther Dyson is one of the people who’s now glommed onto this PHR space, and ran a session at the conference as well as a (damn expensive) day of her own conference on the topic. While I really liked her the one time I met her, I reviewed an early draft of her recent paper on the eHealth space and let’s just say that I don’t think I’ll be writing any papers on Eastern European venture capital any time soon. Oh, and when I met her she was essentially telling a bunch of health plan CIOs that they had to get on the web or die a horrible economic death. That was in 1997. So Esther, be wary of being sucked into our little vortex. Things move very slowly here!
POLICY: Adverse Selection, a young liberal’s learning experience
Sometimes I despair about the young liberals over at Ezra’s blog. Health care is so screwed up and they’re just discovering it. On the other hand they are discovering it and somehow figuring it out. Neil (the ethical werewolf) has written about Adverse Selection: A Big Problem with Private Insurane. Read the comments, ann you’ll notice a familiar name or two come up referring to the Wharton school of ecnonmic fantasy.
Still, good to find out that they are learning–I just wish they’d all been forced to read Enthoven, Fuchs, Evans et al so they don’t have to have it all explained again and again.
HEALTH PLANS/POLICY: High-deductible health plans and how the employer does the math
Marketwatch has an article about how you should choose your high-deductible health plan and as you might expect it goes over ground that has been pretty well trod over here at THCB. Basically it suggests that an employee should guess whether they’re going to be healthy or sick over the coming year, factor in the premium contribution they’ll be asked for by their employer, and balance it out accordingly. (No prizes for guess which you should choose if you know you’re going to be one or the other). But even though the author doesn’t realize it, the really interesting piece is a throwaway at the end about Cigna’s plans for its own employees:
The biggest changes for Cigna Corp.’s 26,000 employees during this year’s open enrollment include a total conversion to high-deductible plans, mandatory health-risk assessments and a 10% break on premiums for nonsmokers, said Catherine Hawkes, director of Cigna’s total health and productivity. The health-benefits company already has 40% of its workers enrolled in high-deductible plans for 2005, most of them in HRAs, she said. But they’ll have the choice of two HRAs and an HSA for 2006. For in-network coverage where the employer has negotiated rates with providers, single HSA plans will have a deductible of $2,000 and families will pay $4,000 up front, Hawkes said. The out of network HSAs will carry deductibles of $3,000 and $6,000 respectively. Cigna also is contributing to workers’ HSAs for the first time in the amount of $200 for single employees and $400 for family plans, she said. And workers will be able to choose from six mutual funds instead of the low-interest-bearing account currently in use. (Bold emphasis added by me)
This explains exactly how things will play out (much, it might be added, to the fears of Eric Novack). The basic problem with HSAs, (as I’ve explained add nauseam–for the math detail dig down in here) is that they allow the individual to pull money out of the risk pool, forcing the pool to find more money for the care of the sick 20% after the healthy 80% have taken their money out. A self-insured employer is a risk pool so there’s no logical incentive for an employer to put money into an HSA that an employee can walk off with. But there is a logical incentive for them to move employees from low or no deductible plans into high-deducible ones and not fund that deductible.
Imagine if Cigna had 100 employees, and paid $500,000 total for their health care in a fully covered pool. Remember that 20 of them will take up 80% of spending ($400,000 at $20,000 each). If Cigna switches to a HDHP and put $2000 cash into each of their HSAs, by the time it came to find the $360,000 required for the sick 20 (the $400,000 minus the $40,000 in their HSAs), it would notice that it had already put $200,000 into the HSAs leaving a hole of $60,000. But if instead it started paying for its employees only when they spent more than $2000, they would now be spending $360,000 on health care for its sick 20 employees (the employees needing to come up with the first $2000 each) and nothing for the rest of them. So Cigna could even afford to throw a couple of hundred bucks into every employee’s HSA because it would all of a sudden be saving itself 25%, over what it cost it before. That’s why the HDHP is proving so popular among employers, because it gives them the ability to reduce their costs while claiming that they are "empowering" their employees.
No, of course reality isn’t quite like this, and Cigna’s employees are probably getting breaks on premium co-shares, and maybe even bigger pay rises that go along with this, and overall it’s a trend rather than an immediate shift. But that is what is going on here, and it’s not dissimilar to the Walmart/Costco situation, where Walmart pays fewer benefits and makes more money. So it’s just more evidence that the abdication of employer-based health insurance is well underway, and being led by health plans who are looking for the next big thing to sell to their dumb employer clients.
This rightly has sensible advocates of market reform like Brian Klepper and Pat Salber very worried. In their opinion piece in Modern Healthcare they note that we are essentially replacing employer-based health insurance with nothing. And that has big consequences for a health care delivery system which depends on third party payment to make up the numbers.
And I guess if Cigna et al eventually finish off employer-based health care by getting their clients out of the business of providing health benefits–well that wouldn’t be a great loss. After all it would mean the plans went out of business too! But I guess that’s slightly longer range thinking than the average health insurer’s management team is used to.
INTERNATIONAL: Monday morning world view
If you thought America was strange consider the plight of my birthplace and its former Empire. For a start the Royal Family is so broke it’s having to send its first-born son out to work for a Hong Kong bank, no less. Meanwhile, at least one junior doctor (resident to you Yanks) thinks that doctors in the UK get paid too much. Finally a great soccer player, George Weah, (who starred for AC Milan in their hey day in the 1990s and played briefly for Chelsea and Manchester City) has decided to go back to his home country of Liberia and take over as President…
On a less light note, the earthquake in Pakistan and India is very, very serious, as are the mudslides in Guatemala. Here is a link to a page with several charities working in relief.
UPDATE: I got Liberia and Cameroon mixed up. Liberia was of course founded by free African-American slaves.
PHARMA/QUALITY/PHYSICIANS: Rational sense on opioid use for cancer sufferers, with reference to Kinsey and rationalism.
A very important THCB reader — one that I have to be nice to if I want to feature in the will, and you might guess that I’m a couple of wickets down already — has forwarded me this BMJ article on opioid use for cancer patients.
Last night I saw the movie Kinsey, which told the story of how Kinsey’s research on human sexuality in the 1940s and 1950s created great advancement in human understanding, and helped remove the weight of hundreds of years of damaging religious bigotry — yup into the 1930s married couples were taught that any non-missionary position sex (including using the mouth or the fingers) was wrong and unnatural. There’s a harrowing scene were his father eventually tells him that he was fitted with a strap to prevent masturbation. I thought of this in the context of opioids, because apart from certain lunatics on the Christian right, rational people agree that the behaviors imposed by society on sexual "deviants" — homosexuality was a jailable offense as recently as the 1950s –were both morally wrong and harmful to individuals and society as a whole. We needed science (and I know there’s a lot of criticism of Kinsey, M&J and Hite’s methods, but they approached the issue from a scientific not a moralistic perspective) to show us the truth in a rational dispassionate way.
The war on pain doctors and patients is being fought by a similar band of lunatic puritans as attacked (and still attack) Kinsey. Only these moralistic jihadists have the full force of the Justice Department behind them and are clearly bending every commonsense understanding of justice and ethics to imprison and destroy anyone who holds a different, more humane view.
Of course the main problem here is that the puritan jihadists have equated opioid use for pain as some kind of great moral failing. Well the scientific view is succinctly and excellently put by a leading British physician:
Concerns about morphine: Morphine has long been feared by the general public and the medical profession. Underlying this fear is the mistaken belief that the potential for misuse of opioids is linked with their use as analgesics. Unfortunately, concerns about addiction, respiratory depression, and excessive sedation cause healthcare professionals to avoid using opioids or to use them in suboptimal doses. Clinical experience has shown that these fears are largely unfounded and that addiction is not likely if morphine is used to manage pain responsive to opioids in doses titrated to the degree of pain. Withdrawal symptoms indicate physical dependence and should not be confused with psychological dependence (addiction).
It’s mainstream educated work like this that needs to be broadcast widely, and all physicians and other scientists need to continue to trumpet this loudly. Don’t forget that the puritan jihadists want to take us back to their equivalent of Sharia law, and the real fight among civilizations is not between Christians and Muslims, it’s between the rationalists and the zealots. And if you think I’m overstating it let me use this quote from the Guardian of a smattering of leading anti-Kinsey campaigners (yup, they really exist)
The religious right still fear and despise Kinsey and all his works. Check out some of the (apparently coordinated) responses to the new movie. "Kinsey’s proper place is with Nazi doctor Josef Mengele," says Robert Knight of Concerned Women for America, inadvertently showing us what he thinks of the Holocaust. Robert Peters of Morality in Media: "That’s part of Kinsey’s legacy: Aids, abortion, the high divorce rate, pornography." Focus on the Family’s film critic (they have a film critic?), Tom Neven, calls the movie "rank propaganda for the sexual revolution and the homosexual agenda". And Judith Reisman, who has waged a decades-long war against Kinsey’s memory, refers to "a legacy of massive venereal disease, broken hearts and broken souls".
And is it a Jihad? Well the lunatics certainly think so:
A recent newsletter of the abstinence-education group Why know? compared the publication of “The Kinsey Report,” in 1948, to the attacks of September 11th, and labeled Kinseyism “fifty years of cultural terrorism.”
BLOGS: World Mental Health Day
Psychologist Deb Serani informs me that it’s World Mental Health Day. Go to her blog to see more, and no snide remarks about which of our nation’s leaders this is aimed at!
BLOGS/PHYSICIANS: Enoch Choi in New Orleans
oDr. Enoch Choi, a medblogger (and OT but BTW a liberal evangelical Christian just so you know there is one!) has packed up his black bag and spent the week in New Orleans following his medical calling. Go read his blog and scroll down to the October 1 entry — then read up. Doesn’t take too long as he’s posting via his Treo and he’s mighty mighty busy. It’s an amazing read.
It’s very clear that the return to New Orleans is fraught with similar perils to the evacuation. Plaudits to Enoch to heading out and putting his God-given talents to work in a crisis. They still need doctors desperately down there.
UPDATE: Enoch writes direct (promoted from the comments). Please consider donating once more to the organizations that are sending committed volunteers like him onto the very front lines.
thanks for the props, Matthew. i’ve come to new orleans with City Team ministries and serving under the local authority of Pastors Resource Council PRC Compassion, invited by the local churches in St. Bernard. Menlo Park Presbyterian Church MPPC paid all of our flights, expenses, medicines and supplies.
Any of those organizations would be able to immediately deploy your donations to people we’re seeing every day. Yesterday, one of our nurses gave us $1000 from their Kansas Church… Their entire disposable cash. We spent it today on natural tears, sunblock, nasal saline, sudafed, lozenges, cough syrup, hydrocortisone. We gave it away in 2 hours. There’s immesurable need here, and whatever you give to MPPC would be immediately consumed by that need by our medical team.
to give to MPPC:
to give to City Team:
to give to PRC Compassion:
This is so different than giving to Red Cross, what you give to them will be spent on the next disaster. The Red Cross doesn’t have physicians down here. I don’t see any other medical teams down here other than ours. There are plenty of individual physicians that have come down, and they’re very important, but as an organized group, we’re it.
POLICY/POLITICS: Linking Katrina, Medicare Part D and bird Flu
Here’s my FierceHealthcare editorial today:
FierceHealthcare has been following two stories all year that both had big moments this week. One is the avian flu that’s been popping up in Asia and may end up being as deadly as the 1918 epidemic. The other is the new Medicare Part D roll-out. For Medicare Part D, the complex mix of plans being offered to seniors will test their ability to understand the options on hand — anyone who’s bought insurance in the individual market knows that’s not easy — and will also challenge the Federal government’s ability to run and police a complex program with many different private and public agencies taking part. Given the nation’s recent experience with a similar challenge on the Gulf Coast, we can be forgiven for looking at the Medicare roll-out as the next great test of government, and hope that it shows improvement. Especially if we have a real crisis in the near future if avian flu becomes the pandemic we all fear.
