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Above the Fold

A Little Context in the Workplace Wellness Debate

Dec 19, 2015• 2

By HARRIS ALLEN

Ms. Dentzer has once again offered a constructive course correction with her commentary on the most recent public installment of the workplace wellness “debate” at the Population Health Continuum’s November 2015 conference. Few have done so with as much clarity and impartiality over the years, and for this she merits this note of thanks. In this instance, for those of us who have followed and at times participated in this debate but did not attend the conference, it is most appreciated.

From her summation of how return-on-investment dominated the exchange, it appears that little new transpired in terms of the debate itself. If one went to the session apprised of the previously stated positions of Lewis and colleagues and of Goetzel and colleagues and of the communications each has published in response to the other, one would likely have left with the sense that no forward movement – either in their exchange or for the debate more generally – had occurred. However, while it is presumably preferable to have not missed out on a catalytic moment, employer investment in wellness remains a domain marked by much capacity to improve the health and productivity/performance in the workplace and communities and, by extension, the value and sustainability of health care reform. Yet, it is also sorely in need of the galvanizing coherence and direction that such a moment would foster.

It’s Still the Prices, Stupid!

Dec 18, 2015• 17

By STEVE FINDLAY

Oh, for heaven’s sake! Just when we thought we knew one important path to retraining healthcare costs—by mimicking what communities with lower Medicare costs do — along comes a study that blows that idea out of the water.

The landmark new research, unveiled this week in The New York Times, found that communities with lower Medicare hospital spending don’t necessarily have lower hospital spending for privately insured people.

That matters because for the last 10 years or so we have assumed that where Medicare costs were high (or low), privately insured costs would be high (or low), — in short, that there was a correlation. It just made sense.

President Obama trumpeted this relationship in the run-up to passage of the Affordable Care Act, sometimes citing Atul Gawande’s now-famous June 2009 New Yorker article on McAllen, Texas. Obama advised health leaders nationwide to study communities with lower Medicare costs and learn from their cost-cutting ways.

Electronic Health Record Data Shows Reports of Hoverboard Risks Zipping Higher

Dec 18, 2015• 1

By HANNAH GALVIN, MD

When I was 10, Marty McFly rode a hoverboard through a 2015 Hill Valley’s Courthouse Square, and I knew what I wanted from Santa that year. Needless to say, I was disappointed that Christmas morning in ’89.

Fast forward to the real 2015, and a tattooed woman in her early 20’s has maneuvered her way off the DC Red Line and onto the escalator in front of me riding some kind of self-powered two-wheeled object that looks like a disembodied Segway. It has a blue neon underglow that gives it the appearance of floating. My calves ache in sympathy as she shuffles to maintain her balance on our long ascent to the street, and I hold my breath as she navigates to solid ground, surprisingly without incident. As she pivots, I ask her the name of this strange new transportation device.

“It’s a hoverboard,” she tells me.

And I know exactly what I want for Christmas this year.

I’m sure I’m not alone in this sentiment. As a pediatrician, I’m also sure I’m not alone in my concern for the safety of kids using these products, just as I was for the young woman riding hers up the Metro Center escalator.

The Magical World of ACA Funding

Dec 17, 2015• 3

By ANISH KOKA, MD

Congressional leaders just agreed to a budget that would keep the government open through September 2016. I was happy to hear the government was not going to shut down. I was much less happy to hear about the fate of provisions supposed to fund the Affordable Care Act (ACA). The ACA – costing $1.2 trillion over 10 years – was supposed to ‘mostly’ pay for itself. Revenue was to be generated (in large part) by a series of taxes on a variety of different sources. These taxes did not fare so well in the current budget.

‘Cadillac’ Tax

The ACA took aim squarely at high cost employer-sponsored plans. Economists believe that since employer health insurance is tax deductible, high cost plans proliferate as a mechanism to provide a tax free benefit to employees. These expensive plans are expensive because they cover most of the cost of medical care, insulating the patient from the actual cost of medical care. The ACA imposed an annual 40% tax on plans with annual premiums exceeding $10,200 for individuals and $27,500 for families to be paid by the insurers. The results were to be two fold: One, create a disincentive for employers to offer ‘cadillac’ plans, and two, generate revenue to pay for the ACA. A broad coalition composed of democrats and republicans lobbied to defeat this tax.

The Massachusetts Medical Society on Meaningful Use

Dec 17, 2015• 4

By MASS MED SOCIETY

Massachusetts Medical Society President Dr. Dennis Dimitri sent the following comments on Meaningful Use Stage III and the Medicare Access and Child Health Reauthorization Act to CMS on Tuesday. THCB is pleased to feature them for our readers. If you agree, we urge you to share with your colleagues, your elected representatives and on social media. – John Irvine

Dear Mr. Slavitt and Dr. DeSalvo:

On behalf of the 25,000 physician, resident and medical student members of the Massachusetts Medical Society I am writing to provide our comments on Stage III Meaningful Use as it relates to the Medicare Access and Child Health Reauthorization Act. It is our understanding that the AMA is submitting extensive and detailed comments on specific aspects of the Meaningful Use Stage III, including a proposed revision of the program which we strongly urge the Department to consider going forward. Our comments will highlight several of the overarching problems with the meaningful use program as currently constructed and its impact on practicing physicians and our patients.

To put our comments into context I would like to underscore that Massachusetts physicians were early adopters of Electronic Health Records. The MMS has been committed to helping our members understand and implement successfully EHRs for well over a decade. We were one of the founding members of the MA EHealth Collaborative (MAeHC) and continue to support this important project which helps physicians choose and implement EHRs in their offices. We understand well the promise of this technology.

Saving Normal

Dec 16, 2015• 8

By SAURABH JHA, MD

The iconoclastic psychiatrist Thomas Szasz said that mental illness was metaphorical, not real, because mental diseases lacked biological substrates. The absence of a substrate predisposes psychiatry to overdiagnosis and avoiding overdiagnosis is psychiatry’s biggest challenge. This challenge has been taken up by Allen Frances in Saving Normal. Like Szasz, Frances writes in cultured, erudite prose. Unlike Szasz, Frances believes that psychiatric illnesses are real. To save the mentally ill, to save psychiatry from itself, Frances says we must save normal.

Six years ago, Frances was enjoying retirement after a distinguished career, minding his business sipping cocktails at the annual meeting of the American Psychiatric Association (APA). Psychiatrists were excited about updating the Diagnostic and Statistical Manual of Mental Disorders (the soon to be DSM-V). Frances had chaired the previous edition of DSM, but in the zeal of the latest edition, he saw diagnostic hyperinflation of a frightening scale.

Why Doctors should Recommend Quantified Self Technologies for Their Patients

Dec 16, 2015

By MOLLY MALOOF, MD

The United States population suffers from staggering numbers of lifestyle related diseases. We know the situation is not improving. Recent research found that over half of the country has prediabetes or diabetes. The facts don’t lie—the vast majority of the US burden of disease are due to lifestyle.

Photo Credit: Dr. DArriush Mozzafarian

People know they should eat less and exercise more, but they don’t. They don’t because without the right knowledge and direction, behavioral change is really hard. Doctors also know they should be advising their patients on lifestyle, but they don’t.

Genetic Testing: The New Frontier of Wellness Madness

Dec 16, 2015• 4

By AL LEWIS

The Wall Street Journal just reported that Genetic Testing May Be Coming to Your Office Soon. This is all well and good, assuming employees would want their health insurer’s buddies collecting their DNA for no good reason, handling it, selling it, and possibly losing it. This is not us talking. This is what the testing company itself says on their website. You can read all about it here.

Instead we will focus on the fact that this scheme simply doesn’t save money – according to the main proponents of this dystopian scheme, Aetna and its buddies at the ironically named Newtopia. Anticipating the day (yesterday) that this would become front-page news, we have already showed how Aetna’s study accidentally showed the opposite of what it intended to show. This is that proof.

The Right Not to Know

Dec 15, 2015• 1

By BENJAMIN E. BERKMAN

While promising to eventually revolutionize medicine, the capacity to cheaply and quickly generate an individual’s entire genome has not been without controversy. Producing information on this scale seems to violate some of the accepted norms governing how to practice medicine, norms that evolved during the early years of genetic testing when a targeted paradigm dominated. One of these widely accepted norms was that an individual had a right not to know (“RNTK”) genetic information about him or herself. Prompted by evolving professional practice guidelines, the RNTK has become a highly controversial topic. The medical community and bioethicists are actively engaged in a contentious debate about the extent to which individual choice should play a role (if at all) in determining which clinically significant findings are returned.

In a recent paper published in Genetics in Medicine, my coauthors and I provide some data that illuminates this and other issues. Our survey of 800 IRB members and staff about their views on incidental findings demonstrates how malleable views on the RNTK can be. Respondents were first asked about the RNTK in the abstract: “Do research participants have a right not to know their own genetic information? In other words, would it be acceptable for them to choose not to receive any GIFs?” An overwhelming majority (96%) endorsed the right not-to-know. But when asked about a case where a specific patient has chosen not to receive clinically beneficial incidental findings, only 35% indicated that the individual’s RNTK should definitely be respected, and 28% said that they would probably honor the request not to know. Interestingly, the percentage of respondents who indicated that they do not support the RNTK increased from 2% at baseline to 26% when presented with the specific case. The percentage of people who are unsure similarly jumps, from 1% to 11%.

Physician Burnout Rates Top 50% in latest Mayo Study

Dec 15, 2015• 8

By DIKE DRUMMOND, MD

Over 50% of US Physicians now suffering at least one symptom of burnout. Depression and suicidal ideation rates even more concerning.

For a while now I have been suspicious that physician burnout rates are increasing here in the USA, especially in the last five years or so. There is just too much political chaos, marketplace M&A activity and documentation overload for it to be otherwise.

Finally the research has caught up with this suspicion in the latest version of Mayo’s landmark 2011 physician burnout study. Here is our smoking gun at last. Unfortunately the numbers are bad and the burnout numbers, though mind boggling, are not the most concerning finding.

Mayo Clinic Proceedings this month published results of round two of their survey of burnout in physicians compared to burnout in the “normal population”. The first round in 2011 was major news across the country and the first study that compared physician burnout rates to those of non-physician workers.

The burnout rates are what I expected. The shocker is the number of physicians screening positive for depression and suicidal ideation that no one is reporting on.