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The Real Problem With Med Student Debt

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By Chhabra, Joseph & Herigon


America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors.

Few people are more aware of the stress of medical student debt than med students themselves, and there’s evidence that it affects our specialty and practice decisions later on down the line.

Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem.

We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.

Allan Joseph (AJ): The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.

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Could Digital Rights Management Solve Healthcare’s Data Crisis?

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By Newman, Herrera, Frost & Parente

Today, academic medicine and health policy research resemble the automobile industry of the early 20th century — a large number of small shops developing unique products at high cost with no one achieving significant economies of scale or scope.

Academics, medical centers, and innovators often work independently or in small groups, with unconnected health datasets that provide incomplete pictures of the health statuses and health care practices of Americans.

Health care data needs a “Henry Ford” moment to move from a realm of unconnected and unwieldy data to a world of connected and matched data with a common support for licensing, legal, and computing infrastructure. Physicians, researchers, and policymakers should be able to access linked databases of medical records, claims, vital statistics, surveys, and other demographic data.

To do this, the health care community must bring disparate health data together, maintaining the highest standards of security to protect confidential and sensitive data, and deal with the myriad legal issues associated with data acquisition, licensing, record matching, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Just as the Model-T revolutionized car production and, by extension, transit, the creation of smart health data enclaves will revolutionize care delivery, health policy, and health care research. We propose to facilitate these enclaves through a governance structure know as a digital rights manager (DRM).

The concept of a DRM is common in the entertainment (The American Society of Composers, Authors and Publishers or ASCAP would be an example) and legal industries.  If successful, DRMs would be a vital component of a data-enhanced health care industry.

Giving birth to change. The data enhanced health care industry is coming, but it needs a midwife.There has been explosive growth in the use of electronic medical records, electronic prescribing, and digital imaging by health care providers. Outside the physician’s office, disease registries, medical associations, insurers, government agencies, and laboratories have also been gathering digital pieces of information on the health status, care regimes, and health care costs of Americans.

However, little to none of these data have been integrated, and most remain siloed within provider groups, health plans, or government offices.

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IDESG Is a Glimpse of Our Digital Future

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By Adrian Gropper, MD

I’ve recently returned from the 7th ID Ecosystem Steering Group Plenary in Atlanta. This is an international public-private project focused on the anything-but-trivial issue of issuing people authoritative cyber-credentials: digital passports you can use to access government services, healthcare, banks and everything else online.

Cyber ID is more than a single-sign-on convenience, or a money-saver when businesses can stop asking you for the names of your pets, it’s rapidly becoming a critical foundation for cyber-security because it impacts the resiliency of our critical infrastructure.

Healthcare, it turns out, is becoming a design center for IDESG because healthcare represents the most diverse collection of human interactions of any large market sector. If we can solve cyber-identity for healthcare, we will have solved most of the other application domains.

The cyber-identity landscape includes:

  • proving who you are without showing a physical driver’s license
  • opening a new account without having to release private information
  • eliminating the risk of identity theft
  • civil or criminal accountability for your actions based on a digital ID
  • reducing your privacy risks through anonymous or pseudonymous ID
  • enabling delegation to family members or professional colleagues without impersonation
  • reducing hidden surveillance by state or private institutions
  • when appropriate, shifting control of our digital tools to us and away from corporations

The IDESG process is deliberate and comprehensive. It impacts many hot issues in health care including patient matching, information sharing for accountable care and population health, health information exchanges, prescription drug monitoring programs, accounting for disclosures, patient engagement and meaningful use, the physician’s ability to communicate and refer without institutional censorship, the patient’s ability to control information from our increasingly connected devices and implants, and more.

Hospitals and health industry incumbents that seek to solve the hot issues raised by health reform are not eager to wait for a deliberate and comprehensive process. For them, privacy and cyber-security is a nice-to-have. Who will pay for this digital enlightenment?

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The Flu Shot and a Patient’s Right to Choose

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By Jennifer Anyaegbunam


Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s  partnership with ThinkWellPoint.  Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.

I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.

Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.

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The Black Box at the Center of Health Economics

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By Richard Gunderman, MD

When Michael injured his knee, he did what any responsible person would do.  He was not incapacitated, and though the knee was painful and swollen, he could get around pretty well on it.  So he waited a few days to see if it would get better.  When it didn’t, he saw his primary care physician, who examined it and quite reasonably referred him to an orthopedic surgeon.  The orthopedic surgeon considered ordering an MRI of the knee but worried that insurance would not cover a substantial portion of the $1,500 price tag, so he suggested a less expensive alternative: a six-week course of physical therapy that would cost only $600 – a quite responsible course of action.

At the end of this period of time, Michael was still experiencing pain and intermittent swelling.  The orthopedic surgeon made another quite responsible decision and ordered the MRI exam, which showed a torn meniscus.  The orthopedic surgeon could have recommended arthroscopic surgery, which would have earned him a handsome fee and generated revenue for his physician-owned surgery center.  Instead he again acted quite responsibly, advising Michael that the surgery would actually increase the pain and swelling for a time and probably not improve his long-term outcome.  Based on this advice, Michael declined surgery.

Though everyone in this case proceeded responsibly, the ultimate outcome was inefficient and costly.  Many factors contributed, but perhaps the most important was the fact that Michael’s physician outlined choices based on an inaccurate understanding of the costs associated with his recommendations.  The orthopedic surgeon thought that the cost of six weeks of physical therapy was 60% less than the MRI.  In fact, however, the actual payment for the MRI from the insurance company would be only $300, not the “retail” price of $1,500.  What appeared to be the less expensive option was actually twice as expensive, and it delayed definitive diagnosis by six weeks.

This story is emblematic of a larger problem in contemporary healthcare.  No one – not the patients, the physicians, the hospitals, or the payers – really understands in a thorough way the true costs of their decisions.  After receiving care, patients routinely receive by mail multi-page “explanations of benefits” that show huge differences between list prices and actual payments.  Most find it baffling to try to determine who is paying how much for what.  Physician practices and hospitals get calls every day from panicked patients who believe that they are being billed for exorbitant costs, when in fact most or all of the charges will be paid by insurance at a huge discount.

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Good News! A Workplace Wellness Vendor Saying You’re Sick Means You’re Probably Healthy

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By AL LEWIS and VIK KHANNA

THCB is excited to announce the first official e-book release from THCB Press, “Surviving Workplace Wellness” by contrarian Wellness industry observers Al Lewis and Vik Khanna.”  What exactly is the “Wellness industry” anyway? How scientific is the “science” behind wellness programs? Are stop-smoking programs a good idea? Should your company really be paying to send employees to the gym?

Should you be using technology to help your employees monitor and understand their health? You may not always agree with the authors (we certainly don’t here at THCB world headquarters, where Al and Vik have started more than a few food fights) but we still think you’ll find this title a provocative examination of many of the fundamental assumptions underlying prevention and wellness today.

You can order your digital copy from Amazon.com here at the discounted price of $9.99.  If you’re a healthcare insider trying to understand the controversies facing wellness or a conscientious wellness professional trying to get a handle on developing a program that works for your employees, this is the e-book for you.

Be sure to look out for upcoming releases from THCB Press in the months to come.  If you’d like to be placed on the THCB Press mailing list to be notified of upcoming new releases, send us an email with “update me” in the subject line.  Author inquiries and partnership requests should go to this same address. — John Irvine

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Prices Drop When Health Consumers Shop Around For Healthcare

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By William H. Frist, MD

Here’s a point most of us can agree on. Tackling ballooning health care costs requires more than insurance reform because the charge and cost structure for health services in the U.S. is inconsistent and irrational. The same quality CT scan that costs $500 at one outpatient facility costs $2,000 at a nearby teaching hospital.

Obamacare’s typical high-deductible insurance plans encourage many cost-conscious consumers to shop around for low-ticket items below their deductible — and that is good. However, the bulk of health care spending is attributable to patients who rapidly blow through their deductible, after which they have no incentive to shop for value. Those 5 percent of people — who spend a whopping 50 percent of the nation’s health care dollars — have little incentive to consider price. With the cost of multiple medications, frequent doctors visits, use of specialists and one or more hospitalizations a year, these 5 percent will exceed even the highest deductible in the first few months of each year.

So what might be the single most powerful tool to slow the seemingly intractable yet unsustainable increases in health spending affecting practically every family in America? “Referenced-based” pricing for health services encourages patients — most significantly, those with the highest costs — to act as smart consumers by seeking the most cost-effective care, even after they have exceeded their deductible.

Here’s how it works. Insurance companies or employers set a limit they are willing to pay for a specified service of excellent quality — say, $1,000 for a CT scan — and communicate that reference price clearly to consumers. If patients choose a location where the charge is below the maximum set reimbursement rate, they pay nothing. If they choose a provider where the charge is higher, they pay the difference.

As patient-consumers shop around for the best price and quality services, competition in the market pushes prices down and value up.

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Are Death Spirals Real? Has Anybody Ever Seen One?

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By THCBist

A THCB reader in Virginia writes:

“As a small business owner, I’ve been following the arguments about Obamacare with a mixture of amusement and total horror. Just when you thought Washington couldn’t screw things up any worse, they find new and creative ways to do exactly that.

My question concerns the phenomenon of the “death spiral” the terrifying sounding scenario that observers predict will occur if not enough people buy insurance. According to this theory, if not enough people buy health insurance, insurers will be forced to abandon unprofitable markets.  As a business owner myself, this argument resonates. But I still don’t get it. This seems like common sense.

It is certainly true that if nobody buys my goods and services, my business will go into a “death spiral.” I will no longer be able to make a living selling my widgets. I will be forced to invent a new widget. Or go get a new job. This is like my kid saying if he doesn’t to play more Call of Duty IV he will go into an “entertainment death spiral” and be unable to do his homework ever again or be a productive member of society.

Or McDonalds warning that if too many people take up vegetarianism, its business will go into a horrible “hamburger death spiral.” So what evidence do we have? I need documentation. Like, let’s say, a picture. Or a YouTube clip.

Seriously, when has this happened? Otherwise, the death spiral thing sounds like really good economic spin to me …”

The Conservative’s Faustian Fear

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By Saurabh Jha, MD

Avik Roy has done the unthinkable. In a recent op-ed title he used “conservative’s case” and “universal healthcare” in the same sentence. And bridged these disparate words by the preposition for.

Spoiler alert: Roy has asked Republicans to embrace universal healthcare.

The Twitterverse is abuzz. An angry Gary P. Jackson, a self-affirmed conservative, tweeted:

“there is NEVER a conservative case for Marxism….especially Universal healthcare.”

Stated differently, universal healthcare is the worst form of Marxism except for all other forms of Marxism.

Thus far Roy has not been asked to produce his birth certificate, which is just as well. Roy, a prolific Forbes columnist and a scholar at the Manhattan Institute, was healthcare policy adviser to Mitt Romney. He is not a cheerleader of the Affordable Care Act.

There are things one may disagree with Roy. However, his short treatise, How Medicaid Fails the Poor, was impressive, as it deftly dealt with Medicaid’s structural problems. That a right-of-center policy analyst would write a book with that title is one of the many ironies I am now accustomed to encountering (the other delicious irony was the love of Cadillac health plans by unions).

In The Washington Examiner and National Review Online, Roy urges conservatives to acknowledge and embrace universal healthcare, in no uncertain terms:

“…[conservatives] have to agree that universal coverage is a morally worthy goal.”

The arguments put forward by Roy are pure common sense. No one objects to public education as “socialized education.”  If conservatives are afraid that universal healthcare means big government, government is already heavily involved in healthcare.

And not just Medicare, which a certain tea party placard asked the government to keep its hands off!
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Pilots with Hospitals, the Chicken or the Egg Problem

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We know that as a health tech entrepreneur, piloting your technology and getting that first customer validation is extremely challenging. There’s frequently the ‘chicken or the egg’ problem. Most providers are unwilling to work with young technology companies that have yet to validate or prove the effectiveness of their product. Meanwhile, health technology companies need that first pilot for a chance to validate their technology. That’s why the New York City Economic Development Corporation, in partnership with Health 2.0, is excited to launch Pilot Health Tech NYC 2014, a program that provides $1,000,000 in funding to innovative projects that pilot new health technologies in New York City. The program seeks to vet and selectively match early-stage health or healthcare technology companies (‘innovators’) with key NYC healthcare service organizations and stakeholders (‘hosts’), including hospitals, physician clinics, payors, pharma companies, nursing associations, foundations, major employers, and retailers.

The 2013 program was a tremendous success, with participation from 25 provider organizations, over 250 innovator companies, 200 matchmaking meetings, 41 joint applications, and finally, 10 pilot winners.  Since ‘Pilot Day’ 2013, an event during which last year’s winners were announced, the inaugural class of Pilot companies has raised more than $14 million in private investment, including $4.5 million in the last six months and their pilots have enrolled more than 1,000 patients. Check out the video below to hear what some of the winners from the 2013 program have to say!

[vimeo width=”450″ height=”315″]http://vimeo.com/84067044[/vimeo]Continue reading…
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