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The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President

Jan 20, 2018• 29

BY STEVEN FINDLAY

The resurgent debate about President Trump’s mental health prompts me to update a piece I wrote for THCB last June. That piece drew lively comments and debate.

It’s also the one-year mark of the Trump presidency.

As The New York Times editorial page recently asked, bluntly, on Jan. 11: “Is Mr. Trump Nuts?”

Since last summer, that question has gained more traction and spurred more earnest debate. The results from Trump’s medical and “cognitive” exam on Jan 12 are unlikely to quell concern. (More about those results below.)

Nearly every major newspaper and magazine has run stories. Print media columnists and TV commentators dwell on it constantly. It’s catnip for late night comedians. It’s been a trending topic on social media for months. And, of course, it’s a topic of discussion and banter almost everywhere you go.

Lawmakers have finally joined in, too, after reluctance for the better part of 2017. Some even render an opinion publicly.

Articles have begun to pop up in medical journals, too—most recently Dr. Claire Pouncey’s piece in the New England Journal of Medicine (Dec. 27, 2017).

And then there’s the book, which sparked Dr. Pouncey’s piece as well other articles and reviews since it came out last fall. I’m not talking about Fire and Fury: Inside the Trump White House by Michael Wolff—although that book is certainly relevant in this context.

Rather, I’m talking about The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Dr. Bandy X. Lee, a specialist in law and psychiatry at the Yale School of Medicine.

NEJM Blasts “Crusade,” Omits that Its Former Editor Launched It

Jan 19, 2018• 11

By MICHAEL MILLENSON

A blistering attack by the national editor of the New England Journal of Medicine against the “less is more” movement in medicine omitted that the publication’s former editor-in-chief played a foundational role in popularizing the idea of widespread medical waste.

The commentary in late December by Dr. Lisa Rosenbaum, “The Less-Is-More Crusade – Are We Overmedicalizing or Oversimplifying?” has attracted intense attention. Rosenbaum berates a “missionary zeal” to reduce putative overtreatment that she says is putting dangerous pressure on physicians to abstain from recommending some helpful treatments. She also asserts that the research by Dartmouth investigators and others who claim 30 percent waste in U.S. health care, in which she once fervently believed, is actually based on suspect methodology.

What Rosenbaum fails to mention is that the policy consensus she seeks to puncture – that the sheer magnitude of wasted dollars in U.S. health care offers “the promise of a solution without trade-offs” – originated in the speeches, articles and editorials of the late Dr. Arnold Relman, the New England Journal’s editor from 1977 to 1991.Continue reading…

A Patient Experience-Based View of the TEFCA

Jan 18, 2018• 5

By ADRIAN GROPPER

Let’s give the Office of the National Coordinator (ONC) credit for trying. In what’s arguably the first significant piece of policymaking, the newly Republican HHS issued a draft Trusted Exchange Framework and Common Agreement (TEFCA) that aims to implement the massively bipartisan 21st Century Cures act mandate to end information blocking. Are they succeeding?

Why should you care? After almost a decade and many tens of $billions spent on health information technology, neither physicians nor patients have access to a longitudinal health record, transparency of quality or cost, access to independent decision support, or even the ability to know what their out-of-pocket cost is going to be. After eight years of regulation, precious little benefit has trickled-down to patients and physicians. This post looks at the TEFCA proposal from the patient experience perspective.

The patient perspective matters because, under HIPAA, patients do not have choice about how our data is accessed or used. This has led to information blocking as hospitals and EHR vendors slow-walk the ability of patients to direct data to information services we choose. Patients lost the “right of consent” in 2002. This puts a regulation-shy administration in a quandary: How do they regulate to implement Cures, when current HIPAA and HITECH-era regulations give all of the power to provider institutions bent on locking-in patients as key to value-based compensation?

The Kentucky Armageddon

Jan 18, 2018• 34

By MARGALIT GUR-ARIE

The Commonwealth of Kentucky, best known for its weirdly colored grass, fine bourbon and equestrian pageantry, is about to be destroyed by the Trump administration. Many will suffer and perhaps die because Kentucky obtained a Medicaid waiver to impose additional and often insurmountable hardships on poor people receiving their free health care from the State. Since all I need to know, I learned on Twitter, allow me to share with you some illuminating insights from the Twitterati.

The evil Republican Governor of Kentucky, Matt Bevin, is salivating at the prospect off changing Medicaid as we know it, which obviously means that poor people and especially people of color will be suffering greatly under this plan. You really don’t need to know more, since this should be reason enough to mobilize the worried wealthy, who are tossing and turning in their featherbeds night after night, searching for ways to save the poor. For those who are neither worried nor wealthy enough to really care, here are the ominous provisions of the Kentucky racist, homophobic and xenophobic plan to change Medicaid (it is all these things because it was not only approved, but encouraged by the Trump administration, and we all know what that means).

Mark Ganz — What’s Your Purpose in Health Care?

Jan 18, 2018

Last week at Health 2.0’s Wintertech, held during “health care’s money week” JP Morgan in San Francisco, Cambia CEO Mark Ganz gave a remarkable talk–one you wouldn’t expect from the leader of a big health insurer. He called out pharma for price gouging, he asked what consumers would think about the conversations we are having, but mostly he asked people to think about why they were working in health care. And he did it with a deeply personal set of stories. Everyone there found it very moving and very important, so I wanted to share it with the THCB audience. It’s well worth your time to watch. — Matthew Holt

The Naming of Things

Jan 17, 2018• 2

By JOE FLOWER

It’s happening across many parts of the federal government, in many sectors. Officials of the National Park Service have been reprimanded for tweeting about climate change. Scientists at the Centers for Disease Control (CDC) have been warned away from seven specific words in their budget documents, including “fetus,” “evidence-based,” and “transgender.”

It is happening in healthcare as well. In previously secret proceedings, revealed here for the first time, representatives of organizations and companies across healthcare are in negotiations with a cross-agency team at Health and Human Services to restructure the language we use around medicine and healthcare.

Science Fiction Coming to Life

Jan 13, 2018• 9

By DAVID SHAYWITZ, MD

Given the size and scope of the annual J.P. Morgan (JPM) Healthcare meeting (I resisted the temptation to say “diversity”), everyone in town – the minority who actually attend the formal presentations, and the many others who show up in San Francisco to meet and network – comes away with a slightly different experience.

With this caveat (and with the explicit reminder/disclosure that I now work at a life science venture fund, and as always, I’m speaking only for myself), I left the meeting with two fairly pronounced takeaways.

JPM: Two Contrasting Takeaways

First, this feels like an unbelievable, almost magical time in biopharma – a colleague described it (in a good way) as science fiction coming to life. Biological technologies, approaches, and ambitions that might have been dismissed as fantasies only a few years ago now are part of the fabric of the industry – and increasingly, it seems, clinical care. Gene therapy, gene editing, cell therapy, immune modulation – these modalities, alone and in combination, are what many in and around biopharma are contemplating, and the sorts of programs many drug development organizations are hoping to prosecute. It’s hardly surprising many JPM participants emerged with the sense of optimism my Forbes colleague Matthew Herper so accurately captured.

I was equally surprised by what I saw – or more accurately, didn’t see – through the lens of data and technology. As I’ve shared on Twitter, in addition to life science opportunities, I aspire to focus on the elusive middle-ground between tech and life science, and identify and invest in grounded, implementation-focused tech-powered startups that can improve how impactful new treatments are discovered, evaluated, and delivered. However, my overwhelming impression from this year’s JPM is that while data and tech may be embraced at the level of the C-suite, and while everyone professes an interest in AI, these emerging approaches and ways of thinking have generally not penetrated most biopharma organizations at the line/operations level, and have generally not yet impacted how these organizations actually approach their basic work of discovering and developing new therapeutics. Exploratory innovation initiatives, of course, abound, as do data wrangling and integration efforts (see here, eg), but these activities as yet seem to have had minimal impact on how most R&D is actually prosecuted within these organizations.

From what I can gather, it’s not a hostility to technology as much as a sense that it’s not immediately clear to most of those in the trenches how (or even whether) the emerging technologies will meaningfully impact the work they need to do, and many are concerned about, or at least wary of, the additional work it may create. Most acknowledge the possibility that big data and emerging analytics will likely be useful eventually, but few see these changes on the immediate horizon.

A Surprisingly Logical Argument in Favor of Head Transplantation

Jan 13, 2018• 2

By ARTHUR CAPLAN PhD & LISA KEARNS

Not since Rene Descartes gazed from his garret window in early 17th-century Paris and wondered whether those were men or hats and coats covering “automatic machines” he saw roaming the streets has the issue of personal identity and your cranium been of such import. Descartes feared a world that he alone occupied due to deception by the devil. Today we face a different mind-body challenge in the form of a devil we know: Italian neuroscientist Sergio Canavero. He recently announced that the first human head transplant is imminent.

For bioethicists, the moral critiques of this surgery practically write themselves: Are we merely our bodies? How can a person so ill as to wish to trade in his lifelong corporeal companion be considered competent to consent to such a drastic procedure? How can family members consent to donate a body that they could very well run into — and recognize — at the beach or gym? What if a left-handed person received a right-handed body? What if a lifelong Chicago Bears fan woke to find himself attached to the green-and-gold-tattooed torso of a former Packers fan? Would transplant recipients need to buy whole new wardrobes? Who will pay?

We were among those early to carry ethical torches and morally indignant pitchforks at this transplant ahead of its time. Caplan not long ago called Canavero’s work “crackpot science,” writing that “everything about Canavero’s activity is ethically wrong” while incisively reminding all that “[m]oving a head is not akin to moving a light bulb to a new socket.” Ever at the forefront of translational bioethics, Caplan was, as is his wont, quick to integrate electrical engineering with bioethics on the frontier of the emerging field he wittily dubbed, cephalogy.

More recently we decided to hole up in our own, 21st-century garrets: putty-colored, fluorescent-lit boxes seven stories above a lower midtown Manhattan block. It was here that we took the time over a lunch of offal things to explore the real risks and benefits of head transitioning, and it was here that we realized that we had been coming at the problem completely the wrong way. Remember good facts make for good ethics. What Canavero is planning isn’t really a head transplant, but a body transplant. “Heads up!” he cried, when he should have threatened, “Bodies down!”

New Evidence in JAMA Shows Insurance Gaps Leave Some Cancer Patients Without Treatment

Jan 12, 2018• 1

BY BAILEY FITZGERALD

“How long do I have?”

The man was just diagnosed with lung cancer.

“That depends,” his doctor says. “What insurance do you have?”

New research suggests that conversations like these may be actually taking place across the country. Todd Pezzi and colleagues analyzed a national database for treatment outcomes for patients with limited stage non-small cell lung cancer, a diagnosis with high rates of response to treatment. The results, reported in JAMA Oncology last week were astounding: patients with Medicare, Medicaid, or no health insurance received different, and often worse, care than those patients with other types of health insurance. These patients were less likely to receive radiation therapy in addition to chemotherapy, part of the standard of care treatment. And they found that patients with Medicare or Medicaid were significantly less likely to survive their cancer than their counterparts with private insurance.

Clearly, the health insurance system is broken if different insurances determine what treatment a patient will get, even when there is a proven standard of care. Forcing patients and doctors to continue under what has been famously referred to as the patchwork quilt of our healthcare system is leaving people out in the cold.

These findings should alarm anyone who may be a patient one day – which, of course, is everyone. For me, a resident in internal medicine, the findings are also disquieting and discouraging. It’s frustrating to think that the best and most evidence-based treatments I spend many hours per week learning about may not even be available for some of my patients. I worry about being a part of a healthcare system where science and ethics take a backseat to billing groups.

The Individual Mandate’s Dead. What Happens Next?

Jan 11, 2018• 6

By STEVEN FINDLAY

The demise of the ACA individual mandate, along with Trump’s and Republicans’ efforts to repeal Obamacare in 2017, will trigger in election year 2018 a new phase of the long-running, bitter battle over the fate of ACA, the insurance marketplaces, and the direction of health reform in general.

Surprisingly, the Democrats appear to have the upper hand for the moment. Republican efforts to repeal the ACA in 2017 were deeply unpopular—only about 20 percent of the U.S. population supported them. Independents and moderate Republicans, in Congress and among voters, were notably opposed. And in the Senate, moderates killed the various ACA repeal bills (albeit by narrow margins).

The Republican tax bill is also unpopular.

Recent special election results in Virginia and Alabama—put Republicans off-balance and on-notice as well. In particular, the Alabama result bends the vote math in the Senate against any repeat ACA repeal efforts in 2018, and very likely beyond.

But, perhaps most surprising, the resurgence of interest in “coverage for all,” universal coverage, and “health care as a right” that started with Bernie Sander’s campaign in 2016 has continued to gain traction, even among some conservatives.