By KIP SULLIVAN, JD

In May 2009 the New Yorker published an article about Peter Orszag, President Obama’s director of the Office of Management and Budget and his chief health policy advisor. The article said Orszag was “obsessed” with the claim by Elliot Fisher and his colleagues at Dartmouth that unnecessary medical care accounts for 30 percent of all US health care spending. Based on these claims, said the article, Orszag had come to the conclusion “that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient …, thus saving billions of dollars.” The article then observed: “Obama is in effect betting his Presidency on Orszag’s thesis.”

If you have read the first four installments in this series on President Obama’s article in the August 2 edition of the Journal of the American Medical Association (the first installment is here  you will readily understand why I begin this essay on Orszag with that quote from the New Yorker. The New Yorker got it dead right. Because the Affordable Care Act would be regarded as Obama’s main legacy, and because Obama assumed that Orszag’s diagnosis of and solution to the health care crisis was accurate, it is reasonable to say Obama “bet his Presidency on Orszag’s thesis.”

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By LYGEIA RICCIARDI (@Lygeia)

At the 10^th Annual Health 2.0 conference in San Diego I had the honor of moderating a session celebrating a group of outstanding patient advocates and activists for their contributions to the field of digital health. They were chosen through a public voting process. The group was inspiring—their stories, sprit, and impact on the crowd was palpable.

In addition to these individuals’ contributions, it’s important to acknowledge the growing impact of patient advocates in aggregate. Thanks in part to the Internet, smartphones, and social media, patients increasingly exchange ideas for diagnosing and managing their health conditions, analyze and contribute data and research, provide social support to each other, and advocate to improve the healthcare system.

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By JIM PURCELL

In early 1970, I was on reconnaissance in I Corps in Viet Nam as a 1st Lieutenant Team Leader with the 101st Airborne Division Pathfinder Team. No, we did not bite off the heads of ducks to impress the indigenous, but we were in “the bush” and were considered in harm’s way.

On a rather ordinary insertion to inspect potential landing zones, I was moving my team from one area to another when we encountered heavy booby trapping. I stepped on one myself without it exploding. But as I moved up from my usual third spot to my slack man to get us off the trail, he stepped on a rocket propelled grenade booby trap that killed him instantly, and knocked me badly about. Only slightly wounded but with profound hearing loss, I literally picked up the pieces, got us extracted, made my way to the Da Nang 95th Medevac, and was evac’d stateside. I was extremely embarrassed to receive a Purple Heart given my slight impairments.

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By NORTIN HADLER, MD

I’ve attended medical Grand Rounds most weeks for the past 50 years. I consider the exercise one of the grander traditions of my profession. I trace it back to the amphitheater at the University of Montpelier where the 15^th C cleric, humanist, author and physician, François Rabelais, first studied and then held forth. By mid-20^th C, Grand Rounds had become a focal point of training and continuing medical education in academic medical centers. A patient was presented whose illness was puzzling, informative, and/or daunting. A member of the faculty considered the clinical challenges in a fashion designed to be illuminating. The front rows of the audience were populated by silverback physicians behind whom various levels of novitiate were seated. It was incumbent on the discussant to engage the interest of all in the audience regardless of their degree of specialization and incumbent on the audience to participate in a lively exchange. By lively, I mean disagreements on points of substance were valued. There was always an element of showmanship. The result was a durable transfer of information and an hour that was memorable more often than not.

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By DEVON HERRICK

A new report from the National Bureau of Economic Research looked at veterinary medicine. Veterinary medicine is different than human medicine in important ways. The rate of pet insurance among pet owners is thought to be less than 1 percent. There are no government programs to provide veterinary care to poor pets or elderly pets.  Indigent pets can be turned away from emergency veterinary hospitals. Health policy analysts have long blamed the inefficiencies that befall the U.S. health care system on our over-reliance of third party payment. A logical extension of that argument would assume pet care should function very different from human medical markets. Yet, despite this theory, the authors found many characteristics of vet care matched human medical care:

1) Spending on care for pets rose faster as a share of GDP than medical care during the past 20 years. 2) Spending is correlated with income. 3) There has been rapid employment growth in the veterinary sector. 4) Pet care also experiences significant spending on end-of-life care.

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By SAURABH JHA, MD

Ben Stiller – one of the few comedians on this side of the pond who can make me laugh – said PSA testing saved his life. I suspect he wasn’t being funny. Mr. Stiller had Gleason Grade 7 localized prostate cancer.

Is he right? 

The honest answer is that we don’t know for certain. Before I get granular, we must visit proof, level of proof, and burden of proof. The statement, “there’s no proof that Stiller’s life was saved by testing for PSA” is correct. But the statement can’t be made without determining on whom the burden of proof lies. Is it on those who say PSA saved Stiller’s life, or on those who say PSA did not save Stiller’s life? Continue reading…

By HILARY HATCH, PhD

When Esther Dyson asked me to participate in a panel at the Louisville Innovation Summit called “Real-world Care Technologies for Medicaid/Medicare Recipients That Institutions Actually Deploy”  next week, I could hear the frustration in her voice in the name of the panel. “Make something useful that people will actually use.”

I stumbled on the word “technology.” What if we said, “real-world care solutions for Medicaid/Medicare recipients that institutions actually deploy.” Is there a difference? Yes. A solution solves a problem. How we solve a problem shouldn’t be the focus.

I think our customers would say, “if you have to do it with technology, fine.” They are not excited about technology. Who can blame them? In health care, technology has created real-world unhappiness, implementation complexity, low morale and a poor user experience for patients and care providers. To our buyer, technology invokes extra steps on the way to getting the problem solved: IT implementation backlogs, security review, and anxiety about data stewardship.

It would be best if the solution was apparent and the technology disappeared.

Which reminds me of this story:

The architect hired to re-design a famous museum pitched his designs to the Board of Trustees as follows: He said, “If you give me enough money, I’ll design you a beautiful building. If you give me more, I’ll make it disappear.” What a seduction!

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By KIP SULLIVAN, JD

This is my fourth in a series of imaginary lectures on remedial health policy for President Obama. My goal is to convince Obama that he relied on the wrong people for health policy advice. I am focusing on three people in particular: Elliott Fisher and his colleagues at the Dartmouth Institute, Peter Orszag, and Atul Gawande.

In my first comment , I criticized Obama for clinging to the belief that the Affordable Care Act has already reduced health care inflation and will continue to do so in the future. I devoted my second comment  to explaining how influential the Dartmouth Institute has been. In my last comment I set forth the reasons why the Dartmouth group’s influence has declined since approximately 2010. 

I devote this comment to a review of some of the evidence that indicates underuse (the failure of the health care system to deliver necessary care) is more prevalent than overuse. Knowing that fact is useful not just for understanding my criticism of Obama but for understanding how flimsy the justification is for accountable care organizations and other managed care nostrums. I have only enough space here to introduce you to the best of the under- and overuse literature. I believe it will be enough to convince you that underuse is more common than overuse. Once you comprehend that fact, you’ll also comprehend that it is neither logical or ethical to base health policy on the assumption that overuse is the only form of inappropriate use we must address. If we view underuse as an equally serious problem, then it makes no sense to promulgate managed care notions (such as shifting insurance risk to doctors) designed to address overuse.

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