I read with interest a recent editorial that opined on the poor evidence for screening in cancer trials. The evidence was judged poor because apparently no screening trial has demonstrated a clear reduction in all-cause mortality, only disease-specific mortality. One example discussed in the analysis reviews the data for colon cancer screening and notes that, while there were a statistically significant lower number of deaths related to colon cancer in the screened group, the total mortality in the two groups was no different. The authors posit that the study is either underpowered for total mortality or that the screened patients may have more deaths due to the ‘downstream effects’ of screening. The provocative conclusion by many a tweet and retweet is that cancer screening has not been shown to save lives. Apparently the path to progress in medicine now must be paved by studies with millions of patients. I understand the desire for more and more data, but I see danger in the sanctimonious protestations of those who can only find truth within the confines of a million-person, randomized control trial. This approach ignores the history of advances in clinical medicine, most of which live far outside of the boundaries of million-strong randomized clinical trials.
Above the Fold
CMS Approval Another National Nod to the Power of Telehealth
Approximately 12 million Americans utilize some type of home health care every year. From home health aides visiting the infirmed in their homes, to physical therapy services to aide in recovery, to medical equipment being used to treat the chronically ill, home health has been a critical component of care management for decades.
One of the Medicare payment requirements for these services is for the prescribing practitioner to have a “face to face” encounter with the patient within a reasonable timeframe. This has widely been viewed as a burden on patients, many of whom face mobility issues and other barriers to meeting this obligation. It has also been a barrier for our overburdened physician supply.
Just recently, CMS published a new rule extending this requirement to states – stating that home healthcare matching Medicaid funds will be linked to this same requirement. But, there’s another component of the rule which mirrors Medicare and will have a tremendously positive impact on the home health care community – the face-to-face requirement can be met through telehealth.
Optimistic Skepticism About the Future of Consumer Healthcare
Healthcare options are changing dramatically. Technological and market developments give people the power to take control of their own health and wellness, now more than ever before. Companies are constantly creating new consumer applications that seek to solve problems across the full spectrum of the healthcare lifecycle. These products include everything from contact lenses that measure blood glucose levels to an application that lets me chat with a psychiatrist at a moment’s notice. But despite recognizing the added convenience and personalization, I’m surprised by how frequently I ignore the sheer variety of products at my disposal in favor of doing things the old-fashioned way. Just this past week, I had to schedule my yearly checkup. Instead of booking my appointment through a service like ZocDoc or DocASAP, I instinctively grabbed my phone and tried to call a doctor. Why?
One reason is that just knowing about the existence of those services didn’t mean they immediately came to mind. Companies in other sectors such as entertainment or e-commerce can habituate customer behavior because their products cater to consumer needs that reoccur on a daily, or at least weekly, basis. This means that, if you can routinely provide a better user experience than your competitors, you establish customer loyalty. This is why when I want to binge watch TV shows, I immediately go on Netflix. Or when I need to buy a new pair of shoes, I always use Amazon. However, changing customer behavior regarding health is challenging because the nature of the behavior is infrequent and sporadic. Most people don’t get sick that often and, when they are healthy, it’s hard to convince them to remember to use app X, Y, or Z in preparation for the future. For a healthcare product to successfully disrupt the status quo, the added benefit or user experience has to be so formative that the person will remember the product the next time around, which could easily be months.
Empathy and Shame
How we respond to patients who are feeling, or at risk of feeling shame can make or break a therapeutic relationship. This is about how I try to respond.
Shame is a negative moral judgement about oneself. Unlike guilt or embarrassment where someone thinks that fundamentally they are a reasonable person who has done a bad thing, someone who feels shame thinks that they have done a bad thing because fundamentally, they are a bad person.
Guilt is when, for example, you feel bad that you forgot to call your mum on her birthday, but you might reasonably conclude that this doesn’t make you a bad person and so you decide to make up for it and call her the next day. Shame is when you conclude that you are (and have quite likely always been) a hopeless son or daughter who is always forgetting the important things in life and feel too despondent even to call the next day.
We should suspect shame in the following situations. A patient misses an appointment because they are afraid of being judged on the basis of their blood tests . Another fails to attend a follow-up appointment after having disclosed a history of child sexual abuse. The mother who took her child to an A&E department takes them to a different department the next day with the same feverish symptoms in order to avoid the clinician who said they were time-wasting the day before.
Situations where patients blame themselves for their perceived failure to take responsibility either for themselves or their dependents can arouse shame. Healthcare professionals have, in addition to their clinical authority, a moral authority and consciously (or more often not) and intentionally (or not) pass moral judgement on their patients’ behaviour if they do not acknowledge shame and self-blame.
Why We Know so Little About ACOs: The Managed Care Culture at Work
This is the third essay in a three-part series in which I explore the answer to that question. In the first installment I blamed this problem on the flimsy definition of “ACO.” ACO proponents “defined” the ACO in terms of their hopes for it, not in terms of the mechanisms ACOs would use to accomplish those hopes.
In the second installment I reviewed a paper published by the Center for Health Care Strategies (CHCS) to document my statement that we have no useful information on ACOs and to illustrate the quandary the hope-based “definition” of “ACO” creates for researchers. I criticized the CHCS paper as well for its cavalier attitude about evidence. The paper relied heavily on press releases and anonymous sources, and ignored the costs providers and insurers incur to set up and maintain ACOs.
In this last installment, I explore the role that culture – the culture of the managed care movement and the larger health policy community – played in elevating the ACO to the status of national health policy and, at the same time, thwarting the production of useful research on what it is ACOs do for patients.
The ACO isn’t the only example of hope-based health policy
If the ACO were the only example of an undocumented and poorly defined health care “reform” that was flogged from obscurity to fame by a few well-placed health policy entrepreneurs, we might dismiss the problems created by the flabby definition of the ACO as an aberration. But the ACO is not the only example of such “reforms.”
To the contrary, the ACO illustrates the norm, not the exception. It is an excellent illustration of how health policy has been made in America since the modern health care reform debate began circa 1970. Over the last half-century, every managed care “reform” that was eventually unleashed on all or large portions of the American populace followed the trajectory of the ACO:
THCB Tech
- More on MACRA, Interoperability and the Post-Meaningful Use World by Andy Slavitt
- Silicon Valley’s Healthcare Problem by Rachel Katz
- Ransomware, Interoperability, Power Outages, Natural Disasters, Oh My! by Merle Bushkin
- Will Feeding Watson $3 Billion Worth Of Healthcare Payment Data Improve Its Decisions? by Ross Koppel and Frank Meissner, MD
- Electronic Health Records: From Ebola to Zika, Fighting the Last War by Shira Fischer
- Love and Measurement by Westby Fisher, MD
- Data Socialism by Saurabh Jha, MD
- Data Parasites by David Shaywitz, MD
- The Patient-Centered Health Record by Peter Elias, MD
More on MACRA, Interoperability and the Post-Meaningful Use World
By ANDY SLAVITT
THCB is pleased to feature acting CMS administrator Andy Slavitt’s comments during a panel appearance at this week’s HIMSS conference. We encourage you to read them closely and with an open mind and add your own thoughts on the steps you think the government should take to improve the federal quality measurement program and improve and promote health information technology. For more on the topic of EHR incentives and the transition from the Meaningful Use program, go read Andy’s last THCB post “EHR Incentive Programs: Where We Go From Here.”
I love working with Karen De Salvo. She can talk in half sentences and I can finish them. We’ve naturally been working together for months on some of the initiatives we’re talking about here, and always check in to compare facts, see if we’re seeing the same thing. We went into these speeches in perfect harmony on what needs to be done.
True story. We exchange drafts and she sends me a note “Andy, I think your speech comes across as very negative. Why don’t you reread with that lens?” I erased the email I’d been writing to her– she’s always too positive for me anyway – and I think I sent her an emoticon of a happy face instead. Now one interpretation is she works with the technology community who by all accounts and from looking around the floor are generally happy. I hear more from docs trying to use technology and that may affect my moods a little bit.
Quality v. Quantity
Impactful news today: Physicians, CMS and major commercial plans, announce simplification of quality measures. "Huge step forward" #aafp
— Andy Slavitt 🇺🇦 (@ASlavitt) February 16, 2016
A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”
Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.
Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”
Indeed, we all deserve uniform quality measures. Equality in quality!
Liberty Mutual: A Blow to Health Care Transparency
The U.S. Supreme Court dealt a blow this week to nascent efforts to track the quality and cost of health care, ruling that a 1974 law precludes states from requiring that every health care claim involving their residents be submitted to a massive database.
The arguments were arcane, but the effect is clear: We’re a long way off from having a true picture of the country’s health care spending, especially differences in the way hospitals treat patients and doctors practice medicine.
It also means that, for the time being at least, we’ll remain heavily reliant on data being released by Medicare, the federal health insurance program for the elderly and disabled, to study variations in health care. ProPublica has used Medicare data to study differences in medication prescribing, surgeons’ complication rates and use of services by doctors, but it’s still not clear that Medicare is representative of all health care in the country.
The court’s decision involves a case from Vermont, one of 18 states that created so-called all-payer claims databases. Vermont’s law called for health insurers, health providers, medical facilities and government agencies to report data on health care costs, prices, quality and use of services to the state. That included employers who pay the costs of their workers’ treatments themselves, and not through an insurance contract. (Self insurance is common for large companies.)
But Liberty Mutual Insurance Co. objected, saying the Employee Retirement Income Security Act of 1974, or ERISA, prevents states from imposing such a requirement on self-funded plans. The idea is that companies that have operations across the country shouldn’t be subjected to 50 different state laws, but instead should only have to abide by rules from one agency, namely the U.S. Department of Labor.
Mr.Trump’s Proposal for the Sale of Health Insurance Across State Lines
Donald Trump’s website has a position paper entitled “Healthcare Reform To Make America Great Again.” And some of his suggested reforms make sense. However, the question of the moment involves Item 2:
“Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.”
This is not by any means a new proposal. Despite being supported by most Republican Presidential candidates, it has lingered around for decades without going anywhere. And for good reason.
The driving argument is that this would permit increased competition amongst insurers which would lower premiums. While it is true that competition might increase, it is highly doubtful that the result would be lower premiums, and there are considerable consumer protection concerns as well.
