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POLICY: On von Eschenbach’s appointment, by Gregory Pawelski

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Greg Pawelski with a view on the new head of the FDA

More and more physicians and patients are turning to individualized therapies to treat cancers. Under this approach, scientists study how an individual’s cancerous cells respond to several drugs. Doctors have learned that even when the disease is the same type, different patients’ tumors respond differently to chemotherapeutic drugs. Treatments need to be individualized based on the unique set of molecular targets produced by the patient’s tumor, and these important treatment advances will require individualized assay-testing which can improve patient survival in chemotherapy for cancer. Assay-directed chemotherapy is an individualized approach to killing cancer. It’s time to set aside empiric one-size-fits-all treatment in favor of recognizing that breast, lung, ovarian and other forms of cancer represent heterogenous diseases, where the tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient’s cancer.

From yesterday’s Associated Press article:

WASHINGTON (AP) — The new acting   chief of the Food and Drug Administration says he will be presiding over a   transformation in medicine as scientists come to understand diseases in a more   detailed way that could improve doctors’ ability to treat patients.   

Now,"We are discovering so much about diseases like cancer at the molecular   level,"said von Eschenbach, a urologic   surgeon by training. "Much of what we have  done … has been based   on a model of empiricism." Soon, doctors will be able to intervene with   medical treatments more effectively matched to a specific patient’s illness.   

Read the rest at USA Today

Dr. Andrew C. von Eschenbach, tapped by President Bush as the temporary   chief of the regulatory agency, said Sunday that discoveries about diseases at "a molecular level" will lead to a new kind of health care. Doctors treat illnesses based on how well other people have   responded to a given treatment. Soon, they will develop a tailored response  built around specific understandings of the patient, the treatment and the   disease, he said.   

HEALTH PLANS: It’s too late Riker, they’ve assimilated them all….

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Today the Wellpoint Borg collective has assimilated the last of the resistant for-profit Federation Blues spaceships that was challenging them in the outer Galaxy. But shouldn’t it be the Empire crushing the rebels rather than being the rebels (or am I mixing two famous sci-fi memes).

Given that the attempts by other Blues to turn for-profit have mostly been nixed, the health insurance now left with a big chunk of regional non-profit Blues, and 6-10 big national for-profit giants (with Wellpoint and United being more gigantic than the rest) and Kaiser and its lookalikes. But there isn’t such a thing as a national health insurance company–all of them are basically still running local market plans, and all are vulnerable to the cream-skimming going on in the HDHP market.

I guess there are some consolidation savings somewhere in all this mix, but I don’t see how any of this revolutionizes healthcare, although it does seem to have succeeded in revolutionizing the bank accounts of lots of execs at formerly sleepy health plans.

HOSPITALS/INDUSTRY: How stupid is Navigant really?

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So Navigant Consulting has been gilding the lily on its expenses in the apparently somewhat shoddy consulting job it’s doing at King-Drew.  Their basic excuse is that their private sector clients (almost all non-profit hospitals by the way) are quite used to not caring about the fact that they do things like leave rental cars in airport short-term parking for a week, take one day trips to work on other clients business, and fly their employees from San Diego to Los Angeles (a two hour drive) on a routine basis, and then send their clients the bill.

So Navigant is apparently dumb enough to think:

a) that their other clients won’t notice them basically calling them dumbb) that the King/Drew contract was sufficiently low profile that no one would care about what they did, despite the fact that the LA Times just won a Pulitzer Prize for investigating other malfeasance at the hospital, andc) that contracts they sign about expense reimbursement policies don’t apply to them.

BTW almost all of my clients either give me a total "capitated" fee for my expenses, or I make damn sure that they have an idea of what expenses are coming down the pike. And I don’t work for anyone who would have to respond to a Freedom of Information Act request!

PHARMA/POLICY/POLITICS: Well at least he gets to put “former FDA Commissioner” on his resume!

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So just like that after a contentious time getting confirmed, FDA Commissioner Lester Crawford resigns, after only formally being in the job for less than three months (although effectively having basically run the agency for three years). I wonder what further skeletons have crawled out of his closet?

Get ready for more confirmation fatigue as the Administration searches for someone else ready to screw their reputation by placing politics (and deeply unpleasant, mean spirited politics at that) before science.

TECH/CONSUMER: Don Kemper wraps up

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Imgp4565In the home stretch now.  Don Kemper, the guru of this information therapy, self-care stuff is up now.  His goal is that every medical encounter ends with an information prescription, which would then drive better compliance and better health outcomes — and by the way save a whole lot of money.

Don wants to pay for IX  by finding all the big disease categories and incorporate IX into disease management.  He things that we need more members for this "billion dollar club".

And to move this along, the Center for Information Therapy is going to become a new, independent center with no direct connection to HealthWise.

And it’s a new dawn for Information Therapy….at least he thinks and we ought to hope.

CONSUMERS/TECH: Data and more impressions from Information Therapy conference

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More from Park City….

Shorter Mark Bard (Manhattan Research)– two thirds of docs are suggesting that younger female patients go to the web, but there’s no financial mechanism for it, and no real business case for physicians to do better websites, eVisits, or anything much else so far.

Shorter Susan Denzter (PBS NewsHour Corespondent) (via phone as she’s on the way to cover Rita) — Consumers don’t understand numbers, they don’t understand simple instructions, and simple numeracy and literacy is a big challenge especially among the elderly and less educated, which is a lot of people. Plus no-one understands (and this includes journalists and drug detail people) the difference between relative and absolute risk. And people make irrational choices even when presented with the correct information. She calls it not Information Therapy, but Information Fughedaboutit. So she asks her sources to talk to her on air as if she’s an intelligent 12 year old. So there are lots of reasons why information is good but no way is it enough to explain behavior.

I’m reminded of the time that at IFTF we put the California HEDIS measurements up on one chart and asked the audience to pick their health plan by looking at it. It was a rainbow of conflicting color-coded circles. No one could figure out until about a year after we’d been showing it one bright guy said "look you should join Cigna Southern California as they do the best on the most measures".  And he was right.  Then we told him that Cigna Southern California was the staff-model Medicaid HMO with clinics in Compton and South-Central LA.  Somehow we felt that that information, even though it was irrelevant to objective care measures, may well have swayed his choice of plan.

HEALTH PLANS/TECH: PHR and CRM for health plans–finally on the way

At the conference I met David Vinson who (unlike yours truly) did successfully sell his benefits comparison analysis company to WebMD and now is running their private portal business for plans. Finally all the stuff I was trying to sell at i-Beacon is coming true and WebMD has convinced Empire, now Wellpoint and others to do this on an ASP basis. They are integrating the PHR, claims and benefit information, and a bunch of stuff creating a consumer CRM experience–all of which I’ve talked about at length, and done so bitterly.

Below is what I say about it in FierceHealthcare today

For many years health insurers have struggled (or refused) to represent the information they have about their members back in useful form to their members. In an era of on-line banking and airline reservations systems, health plans have been badly behind. Finally this trend may be changing, with WebMD Health, on an ASP basis, leading the provision of personal health records, personalized health information and tools and benefit information directly linked to members claims and service use. Senior VP at WebMD Health, David Vinson told an audience at the Information Therapy conference in Utah that the service is up and running at Empire Blue Cross Blue Shield, with other partnerships announced — including one with health insurance giant Wellpoint.

TECH/CONSUMERS: Kaiser and Renaissance, the big and the small

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David Sobel runs Kaiser Permanente Northern California’s attempts to provide patient information therapy — to him there are professional providers and lay providers of health care!

The opportunity is in self-care management.  Ought to be easy for Kaiser–as the incentives are in the right place– but there are "information implementation disorders".

  • Noise overload disorder
  • Professional dominance disorder (medical Hemianopsia — google it)
  • Not invented here
  • Disease specific syndrome
  • Office visit tunnel syndrome (tyranny of doctor visits as a metric)
  • Mindless body syndrome
  • Technophobia

How to get around this? Need to go to the expensive places (chronic disease). Need to get cost-effectiveness data and compare it to other stuff that doesn’t demand data (no business case asked for office visits). Need to tell stories, such as the Healthwise handbook story about a guy who’s wife made him go in to get an arterial blockage taken care of instead of blowing off the pain. Saved an amputation and tens of thousands of dollars.

Need to rename, retrain, integrate Information therapy into everything the doctors do, and into physician continuing education. So KP doctors are asked when they are doing CME, What questions are available to KP members for information about disease XYZ?  But more than that they had to redesign the program about how to make physicians feel better by communicating better with their patients, and 4,000 docs have gone through the program on their own time because it works. Got to re-frame the language.

And of course relationships, champions, values, persistence and proving yourself matter — In other words don’t try to sell to Kaiser! (Oasis, Oceania, anyone else?)

Rushika Fernandopulle runs Renaissance Health, the attempt to set up a model small practice in Boston.

He thinks that despite he’s in a small practice, we need to think big, and we need to change what we’re doing.  We can’t manage the patients condition, because they do it mostly themselves. They’ve kludged together various IT systems. They ask their patients to pay $20-40 a month to keep their panel size down and their extra work (non-reimbursed) up. The most important thing they’ve done is to change the culture so that widget production is not the goal of the practice. They pay patients if they make them wait more than 15 minutes. And their practice works. He loves working there–his patients love coming.

But with that number of patients per docs we’d need 375,000 primary care docs in the US, and they we’d have to take $250 per patient per year away from somewhere else in the system to pay for it.  Worth thinking about though.

TECH/CONSUMERS: Standards for consumer health info

Still in Utah, still at the Information Therapy conference — A session on how to guide consumers to high quality content, that’s integrated with their care, electronically

Shorter Tom Lee (Calif HC Foundation): Standards for consumer data don’t really exist, but integration of all the technologies providers need without that consumer stuff is a bitch…and anyway the standards are being designed for providers. So this is tough.

Shorter Josh Seidman (Center for Information Therapy): PHRs are disconnected from EHR systems, and give data not information. Integrating a real EMR with a PHR with a content system is even more of a bitch. So getting the right info to the consumer when they need it is difficult.

Shorter Leslie Kelly Hall (St. Alphonsus Regional Medical Center, ID): Can we make looking at our info simpler without going to the level of granularity that providers or plans want? So lets not go to the level of complexity that’s more than we need. But there’s political leadership to do it now, which wasn’t there before.

Tom and Leslie agree with me that we need to change the business models to get there, and by the way CareEncentive may be doing that. (That was an interesting presentation, about how to get docs in Oklahoma to follow guidelines by paying them extra to answer questionnaires, and seeing cost reductions to boot). But Tom thinks that to save the day we need clinician organizations to step up and get the organizational, clincal process transformation done.

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