The Health Care Blog – Page 369 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Telemedicine: Competition and Coopitition

Apr 3, 2016

By ALAN PITT, MD

Screen Shot 2016-04-03 at 10.27.51 AM

In 1985 I had the good fortune to study in Sweden. I made many good friends and loved the natural beauty. I also learned a lot about healthcare in what is essentially a socialist country.

Sweden was (and is) by no means perfect. Progressive taxation had disincentivized hard work leading to something of a brain drain. Many of the physicians I met were looking to emigrate. On the flip side, Swedish healthcare was accessible and high quality. The government viewed healthcare as a responsibility and right rather than an option. The relatively small and homogeneous population (8 million in 1985) allowed central planning. On the campus of the Karolinska Institute, their version of the NIH, there were regional specialty hospitals: a hospital for the heart, the G.I. tract, the nervous system, etc.

This contrasts with American healthcare where hospitals offer specialty services on nearly every corner. Here in Phoenix, a patient with cancer can choose from Banner / MD Anderson, Mayo Clinic, Dignity Health / UA Cancer Center, and Cancer Treatment Centers of America, along with several other institutes. How did such choice come about? As a nation, we hold certain truths to be self-evident. Near the top of the list, we believe competition is a good thing. In just about every business open markets lead to higher quality goods and services and ever decreasing prices. Right? So how come on almost every measure Swedish healthcare trumps the American system? Sweden spends half as much per capita

[JL1] but on average its citizens live four years longer.

The Thing About the IoT

Apr 2, 2016

By BROOKINGS INSTITUTION

Screen Shot 2016-04-03 at 11.01.35 AM

In the coming years, the number of devices around the world connected to the Internet of Things (IoT) will grow rapidly. Sensors located in buildings, vehicles, appliances, and clothing will create enormous quantities of data for consumers, corporations, and governments to analyze. Maximizing the benefits of IoT will require thoughtful policies. Given that IoT policy cuts across many disciplines and levels of government, who should coordinate the development of new IoT platforms? How will we secure billions of connected devices from cyberattacks? Who will have access to the data created by these devices? Below, Brookings scholars contribute their individual perspectives on the policy challenges and opportunities associated with the Internet of Things.

The Internet of Things will be Everywhere

Humans are lovable creatures, but prone to inefficiency, ineffectiveness, and distraction. They like to do other things when they are driving such as listening to music, talking on the phone, texting, or checking email. Judging from the frequency of accidents though, many individuals believe they are more effective at multi-tasking than is actually the case.

The reality of these all too human traits is encouraging a movement from communication between computers to communication between machines. Driverless cars soon will appear on the highways in large numbers, and not just as a demonstration project. Remote monitoring devices will transmit vital signs to health providers, who then can let people know if their blood pressure has spiked or heart rhythm has shifted in a dangerous direction. Sensors in appliances will let individuals know when they are running low on milk, bread, or cereal. Thermostats will adjust their energy settings to the times when people actually are in the house, thereby saving substantial amounts of money while also protecting natural resources.

With the coming rise of a 5G network, the Internet of Things will unleash high-speed devices and a fully connected society. Advanced digital devices will enable a wide range of new applications from energy and transportation to home security and healthcare. They will help humans manage the annoyances of daily lives such as traffic jams, not being able to find parking places, or keeping track of physical fitness. The widespread adoption of smart appliances, smart energy grids, resource management tools, and health sensors will improve how people connect with one another and their electronic devices. But they also will raise serious security, privacy, and policy issues.

Unicornius Gorus: There’s More to the Theranos and Zenefits Story

Apr 1, 2016• 1

By FRED GOLDSTEIN

flying cadeucii A Correction to Unicornius Gorus – Theranos and Zenefits

I have a confession to make, my previous piece entitled Unicornius Gorus –Theranos and Zenefits, which identified these two companies as a new species in the Unicornius genus was not correct.

The problems at Theranos, as reported by John Carreyrou at the Wall Street Journal, just keep getting worse. While its now very clear Theranos has a serious problem with their Edison technology and its ability to produce accurate results, what is perhaps even more glaring is their complete disregard for operating a lab within standards.

Along with the measurement errors, the report by the Center for Medicare and Medicaid Services found Theranos:

used unqualified staff,

allowed unlicensed workers to review patient test results

did not properly operate equipment as per manufacturer recommendations,

lacked proper documentation and signatures and

failed to meet quality control standards.

Repealed or Repaired?

Mar 31, 2016• 17

By PAUL KECKLEY

Screen Shot 2016-03-31 at 10.09.59 AM

Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they’d propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.

GOP candidates Trump, Cruz and Kasich say they will repeal the law; Democratic frontrunner Clinton says she will repair it, and her challenger, Bernie Sanders, promises to replace it with universal coverage. Some speculate that candidate Clinton’s plan will ultimately mirror her Health Security Act of 1993 that parallels the Affordable Care Act in many respects. But the law gets scant attention on the campaign trails other than their intent about its destiny if elected.

I have read the ACA at least 30 times, each time musing over its complexity, intended results, unintended consequences and hanging chads. At the risk of over-simplification, the law purposed to achieve two aims: to increase access to insurance for those unable to qualify or afford coverage, and to bend the cost curve downward from its 30 year climb. It passed both houses of Congress in the midst of our nation’s second deepest downturn since the Great Depression. Unemployment was above 10%, the GDP was flat, and companies were cutting costs and offshoring to adapt.

The “Patient Protection and Affordable Care Act” soon after became known as the “Affordable Care Act”, and then, in the 2010 Congressional Campaign season that followed its passage, “Obamacare”. It was then and now a divisive law: Kaiser tracking polls show the nation has been evenly divided for and against: those opposed see it as “the government takeover of healthcare” that will dismantle an arguably expensive system that works for most, while those supportive see it as a necessary to securing insurance coverage for those lacking.

The Case for Case-Based Reasoning

Mar 30, 2016• 1

By FRANK MEISSNER, MD

flying cadeucii Case-based reasoning has been formalized for purposes of computer reasoning as a four-step process^[1]:

Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.

Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.

Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.

Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

Torture the Data Until it Confesses

Mar 29, 2016• 9

By TOM EMERICK

flying cadeucii Did you ever hear the old joke where the boss says floggings will continue until morale improves? Torturing the data until results improve…or the data confesses…is not uncommon. Which is a pity.

In my career I’ve worked with companies with over 100k covered lives the claim costs of which could swing widely, from year to year, all because of a few extra transplants, big neonatal ICU cases, ventricular assist cases, etc.

Here are just a few of the huge single case claims I’ve observed in recent years:

$3.5M cancer case
$6M neonatal intensive care
$8M hemophilia case
$1.4M organ transplant
$1M ventricular assist device

This is not a complaint. After all this is what health insurance should be about, huge unbudgetable health events.

All plans have one organ transplant every 10k life years or so, most of which will cost about $1M over 6 years. A plan with 1k covered lives will have such an expense on the average of every 10 years. Of course the company may have none for 15 years and two in the 16th year. The same goes for $500k+ ventricular assist device surgeries.

Milestones or Millstones?

Mar 28, 2016• 1

By RICHARD GUNDERMAN, MD and DAREL HEITKAMP, MD

Gunderman Good intentions do not necessarily lead to good results. A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education. In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.

The goals behind the milestones initiative are laudable. Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes. They would foster self-directed learning and assessment and provide more helpful feedback. In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.

In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties. Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin. In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.

Seven Pillars of Trumpcare

Mar 26, 2016• 18

By SAURABH JHA, MD

flying cadeucii It is possible that in a few months from now, only Nate Silver’s prediction models will stand between Donald Trump and the White House. I will leave it to future anthropologists to write about the significance of that moment. For now, the question “What will President Trump be doing when he is not building a wall?” has assumed salience.

This is relatively easy to answer when it comes to health policy. Just ask what people want. Seniors don’t want Medicare rescinded. Even the free market fundamentalist group, the Tea Party, wants Medicare benefits as they stand. At one of their demonstrations against Obamacare a protester warned, without leaving a trace of irony, “Government, hands off my Medicare.”

Rest assured, Trump will protect Medicare. Even raising the eligibility age for Medicare may be off the cards as far as he is concerned. He has promised that no one will be left dying on the streets. That people no longer die on the streets, but in hospitals, because emergency rooms must treat patients regardless of their ability to pay, is irrelevant. The point is that Mr. Trump knows that the public values their healthcare. Trumpcare will show that Trump cares.

Patient-Centered Service

Mar 26, 2016• 13

By ROB LAMBERTS, MD

flying cadeucii American healthcare has a customer service problem. No, customer service in the US is terrible when it comes to healthcare. No, the customer service in the US healthcare system is horrendous. No, healthcare has the worst customer service of any industry in the US.

There. That seems about right.

What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice: