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TECHNOLOGY: HIT conference….Interoperability

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So I spent part of yesterday at the HIT meeting west in San Francisco.  The most amusing session has Molly Coye  pretending that she’s the governor, and apart from the wisecracks about steroids and occasionally forgetting that she’s supposed to be pretending to be a Republican, there is some serious discussion of how information exchange between systems in California might work. This is the creation of the RHIO (regional health information network) to get to that mythical state of  inter-operability.

The CMA rep (Jack Lewin) believes that his members–all those poor solo surgeons struggling by on $200K plus a year–can’t afford EMRs or any inter-operability and shouldn’t be given an unfunded mandate to get on it.  In fact he thinks that if a RHIO made health plans better off due to the elimination of duplicate testing, then they should be taxed $25 per head to pay for all this.  I don’t think that Arnie Milstein (Med Director of PBGH) representing the employers. They are not too interested in paying any more than "their fair share". On the other hand Bob Margolis (CEO Health partners, the second biggest group in California with 1,000 docs) thinks that the state and Federal government should just piggy back off the private efforts.  In other words let Health Partners connect to Kaiser and hope everyone else can hang on. No reason for those two to slant it to their advantage, is there?

Well at least they are all talking about business models and there does seem to be some agreement that there is money to be saved, at least if anyone’s information was available when they showed up in the Emergency room. So that may be a place to start, as it appears to be in Indianapolis, but while (as Jeff Rose says) at the end of the day people want to do a good job, waiting for that to happen may take a long long time if no one’s funding the inter-operability. In fact in Santa Barbara there are, after all that time and money from the CHCF, only 50 odd doctors are on the system.

David Lansky (Foundation for Accountability) on behalf of consumers pointed out that the industry is getting $10,000 a year from each consumer and yet it hasn’t got enough money, wants more….and the industry is having the meeting about moving the consumer’s data around without telling the consumer about it! (The only funny line so far!). He wants consumers to get a seat at the table, and wants the product to serve the public more than the industry.  Plus he wants privacy and auditability, and for the info gathered to used for report cards, quality and who to go to–in other words accountability! And he warns that if industry does this without the consumer, then the consumer will torpedo it later (shades of the backlash against managed care).

So how to move things ahead? Jeff Flick from CMS likes demos, like the small and hard to find (unless you know how to spell it) DOQ-IT program. He also likes putting up data for consumers — Medicare has done it for nursing homes and home health. Their comparative data is changing behavior and being accessed by consumers, but at the moment they don’t have the data for the rest of the system, especially doctors.  In the end though he thinks that a successful RHIO will allow access to that data —  another good reason for providers to resist it.

Jeff Fickenhaser (ex WebMD now CSC) says that to get RHIOs to work you need a) organization — all sides at the table inc payers and providers, b) leadership, c) clear sense of where the money will come in and where the value is created, and d) the data has has to be transparent.

It all sounds very like a CHIN meeting in the mid-1990s  I hope it has a better outcome, but I still see no reason why it will. There doesn’t seem to be any common ground and there doesn’t seem to be any money or business reason to do it. And that’s not my idea, it’s what David Brailer himself said at the last HIT conference out here.

BONUS : Great quote from Arnie Milstein"My aim is to change the direction of begging"

(That is begging from medical directors and quality people having to beg physicians to get involved to the other way around because the market is going to punish them if they don’t)

BLOGS and BLOGGING: Is Joe interesting

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I met a leading luminary from America’s physician world yesterday, and he questioned whether (at least one of) the "Interesting health care people" list I have in my right hand blog roll were really interesting.  So should I change it to "somewhat interesting health care people"? Chortle, chortle.

TECHNOLOGY: And you thought drugs got on the market too quickly and easily?

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I’ll be at the HIT West conference later today hopefully with a little live blogging if things go well.  But meanwhile two articles over the weekend persuaded me that plus ca change plus c’est la meme chose in the wacky world of American health care.

15 years ago I wrote a thesis on the spread of laproscopic cholestectomy (gall bladder removal), which replaced both the conventional surgical method and a sound wave machines called a lithotripter to blast the gallstone. Lithotripsy didn’t actually work in that the gallstones tended to reform later.  Lap choles did work, and were self-evidently better than laparoptomy (surgical dissection and removal).  But in the case of a new surgical technique or procedure, there is no clinical trial required before it hits the market. Lap chole was popularized by a Tennessee surgeon called Eddie Jo Rickett.  In his heyday in the late 1980s, he was teaching other surgeons how to do it 50 week for a couple of grand a time.  He made so much money that (if I recall rightly) he quit surgery and became a country and western singer. Of course everyone had converted over to lap choles without any big clinical trial, just as lots of hospitals had bought million dollar lithotripters who’s main use a couple of years later was as a doorstop. Meanwhile the quick spread of lap choles also produced some real horror stories.

A decade further on not much has changed.  Today’s trendiest surgery is bariatric bypass (or stomach shrinking).  You might think this is pretty rare but there were over 150,000 done last year in the US including weather man Al Roker. However, just like lap choles and anything else that’s spreading fast, there’s not really any good trial data that shows it’s an effective treatment in the real world.  This fascinating and long article in the St Louis Post-Dispatch shows that like lap-chole and laser eye surgery, bariatric surgery has become a cash cow for some hospitals, and a stampede of surgeons learning the technique has massively increased its use.  Of course the backlash is starting and patients including former proponents of the surgery are starting to come forward with a litany of complaints, and many professionals and facilities are either getting out of the business or are starting to offer repairs on the shoddy work that’s being done. The article starts with this grim story:

She dropped from 302 pounds to 126 after her gastric bypass surgery in 2001. Since then, she’s become a strong advocate for other patients,
providing encouragement and advice to hundreds who have had weight-loss
operations. She arranges visits to the hospital rooms of people just
undergoing the surgery. From her home in Cincinnati, she runs a support
group called "Midwest Losers." Her work was honored with an award last
October at a national surgery trade show. But she’s paid a price to be thin: Five surgeries in four years for
related problems, including two hernias and three small bowel
obstructions. She was just diagnosed with a crippling vitamin
deficiency.She’s 41 now. She wonders how much more her body can take. "I’m second-guessing everything right now," Pierce said recently. "Is this what I have to look forward to the rest of my life?"

The point is of course that these surgeries spread in an uncontrolled fashion.  While there’s been plenty of criticism of the FDA, there just is no equivalent body demanding a clinical trial of surgical procedures, and any government agency that even dares to suggest such a thing needs to be wary of the fate of the AHCPR which fell foul of some Texas back surgeons in the mid 1990s and damn nearly was killed off by the surgeons’ friends in the newly Republican Congress.

The only time that surgery tends to get a clinical trial is if Medicare does one (which is rare) or if it involves a medical device regulated by the FDA. That’s just happened in the case of the drug eluting stents (DES).  A new study shows that the DES (Taxus from Boston Scientific and Cypher from J&J’s Cordis unit) both are much more effective than bare metal stents. (Incidentally both stents worked equally well and a new one from Medtronic coming on the market next year did just as well too. In any other industry you might expect a price war, but here don’t hold your breath)!
So at least there’s some good news that the trial proves these things are helpful.  But let’s consider two things.

1)  Virtually anyone who needed a stent was already getting a DES. Even despite the manufacturing problems both major stents have had and an entire recall of the Taxus stent last year, their use has been growing like crazy and they are the dominant treatment of choice for early stage heart blockages.  All this happened well before any clinical trial results came out. So what was the point of the trial? I guess it was like phase IV post market surveillance in the drug world.  But if the results had been bad, would it really have stopped Taxus and Cypher in their tracks? I doubt it.  Why? See reason number two.

2) Because the trial is comparing DES to a treatment that is known to be pretty useless.  The Bare Metal Stents have a high degree of re-occlusion. In other words the arteries they are placed in clog up again anyway. In late 2003 a Stanford study showed that that stents were less cost-effective than traditional by-passes. So the real challenge for the DES is to prove that over time they are more cost-effective than CABGs.  Do you expect to see that clinical trial any time soon? Nope, neither do I.

So 15 years on from the lap chole and lithotripsy story, we still don’t have anything like the clinical controls over new types of surgery that the FDA imposes over drugs.  And you may have noticed that some grumpy people have been complaining that the clinical trial and surveillance system for drugs is too lax!

 

POLICY: Medicaid muddles on

Today’s story about California hospitals suing Medi-cal comes on the heels of a
week of meetings between state governors and the Bush administration about
Medicaid. Medicaid has long been a dog’s breakfast of American health policy
with all types of programs thrown together. It’s a health insurer for the very
poor, it’s a long-term care plan for some of the elderly, it’s a subsidy program
for large inner city hospitals (the DiSH program), and it even pays Medicare
Part B premiums for those "dual eligibles" too poor to afford them. In addition,
in many states the CHIP program for near-poor children is rolled into Medicaid
too. Furthermore, many states use what are now called by HHS secretary Leavitt
"accounting gimmicks" to get more of their program on the Feds’ tab.

The problem is that all these programs tend to be underfunded anyway, and in
a time of state and federal budget squeezes, they come severely under fire.
Taking even another $6 billion per year out of the program, as the
Administration proposes, feels to the states like getting blood out of an
already over-squeezed stone–even if the GAO says its only $5bn a year. A rational system would somehow fold Medicaid into
some type of universal insurance system. But we are not getting that any time
soon, and right now many poor Americans and their safety net providers rely on
Medicaid to keep them from toppling into the abyss. So expect the politics of
desperation to play out in that sector over the next few months.

This is not going to be a fun time to be either a Medicaid recipient, or worse someone who would like to be.  And that includes a lot of young and poor children.  It’s also not going to be fun to be a safety-net provider who relies on Medicaid as one of their better payers.

PBMs: Express Scripts net surges

From the "why does this keep happening?" file, it looks like the PBM sector is continuing to remain very profitable. Today it’s the turn of Express Scripts to announce that  its earnings were up 13 percent. It also revised up expectations for next year.  The stock rallied about 7%.

THCB continues to be baffled at how the PBMs and other health plans are getting away with this.  After all this is a group that has had no success in saving its clients’ money on drugs in the last 10 years, and a recent survey showed that fully one-quarter of employers believe that PBMs are responsible for increasing their drug costs.  But with the Medicare drug benefit giving the PBMs increased visibility and access to a whole new market of customers, it would be a brave short seller to look for the top to the stock here.

TECHNOLOGY: Nine Tech Trends and one big barrier

I am wrestling with a much longer piece on the EMR than I was hoping it would be, but silly me I’ve got myself mired in CHINs, ePrescribing and RHIO.  And given that I’m going to see Duran Duran tonight I will doubtless be further into "Rio" before I’m done, and hopefully she’ll still be dancing in the sand…

So meanwhile go look at these pieces.  In the first Healthcare Informatics features Nine Tech Trends that it thinks are hot in health care. I’m not certain that the list is quite correct, but it’s well worth a scan and I do like this one quote from a hospital CIO in New Jersey:

"I really think we’re just beginning to see digitization," Sharrott
says. "I think if we’re talking 10 or 20 years out, the amount of
integrated digitization is going to be amazing."

Meanwhile the ever wonderful Jane Sarasohn Kahn has her wrap up from HIMSS over at iHealthbeat. She pretty much confronts the inter-operability issue head on. 

Finally, Brailer is very concerned that adoption will be done in silos,
creating more IT fragmentation and an even greater barrier to
interoperability. This is a very real possibility because in the United
States we’ve made an art out of building a fragmented health system
based on outmoded regulations, unchecked competition and other
externalities. The great value for Americans and the national economy
in achieving interoperable health information networks will be what
Brailer calls "the ubiquitous sharing of patient information."

The
leap of faith here is that nationally interoperable health information
networks will be developed as regional programs adopt sharing through
open standards and convergent business practices and policies. As
Brailer characterized, interoperability will occur "not from the top
down, but inside-out."

Developing interoperable health
information systems will require the collaboration of the broad range
of stakeholders in communities to give up their proprietary data
concerns and ante up cash and a collective spirit.

PHARMA: DTC WARS, Epsiode IV (with more apologies to George Lucas)

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Apologies in advance, THCB goes back into movie mode once again to discuss the somewhat arcane subject of DTC Rx marketing…..

YoderA long time ago in a universe far, far away a bright young survey researcher enrolled with some fellow Jedi warriors to make the universe safe and easier for the pharmaco guild to better target the right citizens of the galaxy with the right message about their wondrous potions. The Jedi warriors wanted to build a great database that would create a Beacon to tell the noble pharmaco guildsmen which of the citizens of the galaxy were responding to their clarion calls, and how they ought to change the sound and direction of those calls.  Their goal was for the the noble pharmaco guild to spread health and prosperity while increasing the general well-being and respecting the sanctity of the galaxians’ information as mandated by the Emperor’s HIPAA army — while cutting down on the spending on those pesky airwave borne messages that ineffectively carried the narrow message far wider than it needed to go and surrounded every spare moment of the great Seers’ nightly network prophecy.

Well, as is common in these stories, this episode opens with our band of Jedi heroes distributed to the four corners of the galaxy. Their mighty Death StarData Base was never properly completed before a cold wind crashing down from the NASDAQ quadrant blew fear and loathing into the heart of the great vulture capital birds, and they ceased flying around the universe distributing their nourishing droppings which had kept the Jedis warm and safe while they built their great i-Beacon. Oh, how the poor Jedis suffered, as did many of their fellow warriors in the freedom loving Dotcomposition and many were forced into exile for lengthy periods, marooned on the tropical beaches of the land with the Faraway Thais.

Indeed while the Jedis endured their exile, the pharmaco guild kept sending out its messages, a little less in some years but again with greater volume in 2003 and 2004, mostly because of the need to let the galaxy celebrex the nexium generation of wonderous potions. But the pharma guild still had to rely on the whispers of Oracles and Monitors to figure out if their message was getting across.

Indeed the Monitor which drew its wisdom from a mere 6,000 voices empaneled across the known galaxy continued to tell the noble pharmaco guild that indeed their clarion calls to the undifferentiated hordes known as the health care consumer were "increasingly believable and likeable". Now the brave pharmaco guild members really believed that sending their messages of health and happiness helped their mission.  And there was some reason to believe that it was true. Indeed the green eyeshaders at the Imperial Senate reported that:

DTC advertising appears to increase prescription drug spending and utilization. Drugs that are promoted directly to consumers often are among the best-selling drugs, and sales for DTC-advertised drugs have increased faster than sales for drugs that are not heavily advertised to consumers. Most of the spending increase for heavily advertised drugs is the result of increased utilization, not price increases. For example, between 1999 and 2000, the number of prescriptions dispensed for the most heavily advertised drugs rose 25 percent, but increased only 4 percent for drugs that were not heavily advertised. Over the same period,prices rose 6 percent for the most heavily advertised drugs and 9 percent for the others. The concentration of DTC spending on a small number of drugs for chronic diseases that are likely to have high sales anyway and the simultaneous promotion of these drugs to physicians may contribute to increased utilization and thereby increase sales of DTC-advertised drugs.

But the pharmaco guildsmen still didn’t know nearly as much about their messages as their friends in the consumer packaged goods guild. Where were their ACNeilsen data on the citizens of the galaxy’s consumption habits? They couldn’t track whether their citizens saw their messages and bought their drugs because they couldn’t link their viewing, activity and usage data together safely?  And where was the data broken down by planet and type of citizen? In marked contrast, they did know much about the potion-prescribing habits of the Shamans who were overwhelmed by visits from their drone detail armies because they were told the answers by the all-knowing Xponents of the IMS.

In the good times perhaps these details didn’t matter very much. For example a group of wise men in an ivory tower quoted by the Oracles at Brandweek (Ed: don’t be fooled by the anti-pharma group hosting it, this is a balanced article) found out this :

A study by Harvard University’s schools of medicine and public health, published in 2003, found that for every 10% increase in DTC
advertising, drug sales rose 1%. That does not sound too impressive until it is translated into hard
cash: Every additional dollar spent on DTC yielded an average of $4.20 in sales.

So perhaps there was no need for the pharmaco guildsmen to be able to link the real uses of their potions in real people to the messages they were sending out; for a wise man once said "if you cast enough mud against a wall some will stick up there".

But then came a pestilence upon the pharmaco guilds. All at once the flood of wondrous potions coming down their great pipeline from the wells on the planet Arandee began to slow. In woe the guildsmen looked at each other and searched hard in the neighboring planets of Bio and Tek. But to no avail, and their creditors and bankers from the iBanker guild over on the Street of The Impassable Barrier, took askance at their new found woes. Many pharmaco guildsmen who’s life had seemed as happy as walk through a field full of daisies in one of the allergy messages found that their bankers, schering a fall in their profits, had mercked down their stock price.
And worse was to come.

Some of the wondrous potions were perhaps not quite as wondrous as the pharmaco guildsmen had first said, and and some heretics declared that the messages of the guild were not to be trusted, and even had hidden the truth from the good citizens of the galaxy in their messages. Still other heretics released satirical songs suggesting that anyone believing the messages was a dumb as a mark at a carnival, and some of the guilds members took fright and began to dismantle some of their detail drones that visited and policed the shamans in every nook of every planet.

Then even the guildsmen’s friends who lived in the Imperial Bureaucracy in the friendly city of Effdeeay suggested that the guildsmen might need to quieten their messages and even told the guildsmen to stop them all together for the mysteriously troubling potions known as Cokstoos. And the great bastions of information across the galaxy began to suggest that the overbearing amount of the messages was counterproductive and might even be beginning to have a wearying effect on the citizens of the galaxy. There were even calls for the messages that surrounded the all knowing Seers delivering their nightly prophecies to be banned altogether, and for the power of persuasion to be used only on the shamans and not to be taken direct to their supplicants. Even the noted wise MackMan who was a good friend of the pharmaco guildsmen suggested that the time had come to change their tune and to understand that they couldn’t escape all culpability with a quickly read disclaimer.

But the lone Jedi survey researcher looked on from his lonely exile in a planet on the far left coast of the galaxy, and his mind wandered.  He wondered if the pharmaco guild, too, might not have been happier if they had been able to better target their messaging. Perhaps they didn’t need to surround the seers with messages about their potions as they prophesied, and perhaps if they hadn’t the prophecies would have not been so nasty about the pharmaco guildsmen quite as often. Perhaps they didn’t need to persuade the not-really sick that they had another dread aliment.  Perhaps instead they needed a way to connect just with the citizens of the galaxy who could truly use their help. Perhaps they could benefit from knowing what those citizens who had problems that they could help were doing in their everyday lives, and how they could target them more effectively, and hand over less money to the Seers’ employers in the process.  The lone Jedi wondered wistfully if the Force might ever return to the DeathStar Data Base, and if it would one day be able to help the right citizens hear the right message from the guildsmen, without pissing off the rest of the universe.  Would the pharmaco guildsmen change their tune, or would they
stubbornly continue on to ultimate humiliation in the next great battle
to come?

The lone Jedi sighed. The Force was weak. He saw no way to recreate the DeathStar Data Base by himself.  But he began to realize that his fellow warriors had been on the cusp of a great thing before they were scattered to the four corners of the galaxy. And he wondered if an alternative universe of anonymity protected one-to-one marketing wouldn’t just have been better for the pharmaco guild, the citizens and the galaxy. Perhaps the prophecy of old would come true and a new Jedi would be found to lead the warriors, but the lone Jedi didn’t see much hope.

PHARMA: John Mack on the Pharma Elephant in the FDA’s front room

John Mack has an excellent article in his Pharma Marketing Blog called FDA Advisory Panels: Elephants in the Room. I’m glad he wrote this so I don’t have to.  The news is that 10 of the 29 panelists had active ties (i.e. money) to Pfizer and Merck, and that those 10 voted in favor of keeping Vioxx and Bextra on the market.  As both those votes were pretty close, the quote unquote unbiased panel members voted to remove them from the market, and the quote unquote biased panel members were responsible for the swing vote, which by the way resulted in bumping up Merck’s stock some 15%.

But  as Mack points out, there’s really no one who works closely with pharmaceutical development who can possibly avoid taking money from pharma in one way or another. Either they are advocates who are paid to promote the drug (key opinion leaders) or they are having their research supported by one pharma or another.  Or they are developing their own products and are hopeful of pharma support in the future. And of course these are open government panels so every pharma knows who’s for you or against you! 

This deal was made back in the early 1980s when the biotech industry emerged and scientists were allowed to take their government-supported research into the private sector. Since then the dividing line between government-supported and conducted research and the private sector has more or less disappeared. To put it back firmly into place so that there are "unbiased government experts" available with no ties to the industry they are making decisions about would be a huge reform. Not one that, even post-Vioxx, there seems to be much appetite for. So realistically these conflicts of interest will continue by necessity and we’ll just have to rely on the personal integrity of those involved and look hawkishly for pharma’s reaction to individual votes.

POLICY: Disappointing Presidential silence about illicit drugs reveals bankrupt policy ideas

Not that anyone can be in the least surprised, but it’s clear from the tapes secretly recorded by one of his henchmen that in 1999 Bush privately admitted to both taking marijuana and cocaine in his period of "youthful indiscretion". There’s been a surprising lack of comment about this other than this one article in the Chicago Tribune called the Disappointing presidential silence about illicit drugs. The incredible hypocrisy in which Bush feels that his drug use was a "wild, youthful indiscretion" but that any current drug use by a young person is a seriously punishable offense leads to two terrible consequences for society.

First, Bush has presided over an Administration which has dramatically gone after anyone who remotely disagrees with it on the drug issue, including medical marijuana advocates and pain doctors, with the full force of draconian drug laws. It has also left more than 33,000 young people unable to attend college because of the heinous HEA amendment than bans anyone with a drug offense of any kind getting a Federal loan.  Let’s not forget that has this law been in place in the 1970s that number ought to have included Bush and former Eli Lilly exec, and current Indiana governor Mitch Daniels who was convicted of low level drug dealing at Princeton. The hypocrisy and lack of contrition from those holding this position is unspeakable.

Second and much more seriously, the ridiculous head-in-the-sand antics of the government (and this includes both Republican and Democratic Administrations and Congresses over the last 30 years — although the Republicans are clearly worse) on drugs means that the appalling social and health impacts of drug abuse are essentially allowed to go unchecked, leaving the taxpayer and the health system to deal with them. There are some very interesting models in harm reduction, and drug maintenance programs that have enabled addicts in Switzerland, the UK, Germany and now Canada to live relatively normal lives at little cost to the taxpayer and with minimal impact on society — as opposed to the huge amount of crime and personal cost seen in the unregulated activities of addicts here. But no one in the US will even discuss these models.  Instead
we allow the war on drugs to continue to fill the coffers of law enforcement departments and criminals and dictators across the world, and force taxpayers and health care workers to keep paying for it.  That no fuss is made about the fact that the current President essentially admitted to drug use in his twenties, shows how we’ve accepted this appalling situation as being only too normal.

BLOGS AND BLOGGING: Teething troubles

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There’s been a little bit of teething problems this week, and that with a bunch of other stuff going on with me means that not much happened here today.  Two quick notes.  1) If you have any suggestions about font type, color for reading, printing, etc, or indeed anything else about the look and feel, please let me know by email to matthewATmatthewholtDOTnet  I really appreciate the comments I’ve had during this transition period.

Monday will be  a bigger better day with articles about DTC and EMRs. I will be returning to the late and not too lamented Star Wars motif, so I encourage you to go read the one I wrote in that style a while back.

assetto corsa mods