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The Other Penn State Scandal

Aug 12, 2013• 69

By Vik Khanna & Al Lewis

It’s one thing to lead by example and quite another to be made an example of. The executive leaders of Penn State University, who have managed to generate quite enough terrible publicity over the past couple of years, have now gone boldly where no employer has gone before. By implementing a coercive, intrusive, and wasteful “wellness” program during the academic year’s summer doldrums and miscalculating that it would go unnoticed, they have invited the wrath of their own faculty.

The PSU wellness initiative like so many before it relies on the hydra of preventive medical care, which is both clinically and fiscally ineffective; a personally intrusive health risk appraisal; and, a whopping incentive/penalty of up to $1,200 per year if you don’t play ball, which is double the national average. Penn State faculty, led by political science professor Matthew Woessner of their Harrisburg campus, have responded with outrage and a petition for withdrawal of the program, which now has 1,500 digital signatures. Penn State’s HR team, led by VP Susan Basso, has doubled down on its own ignorance claiming that the opposition is “unfortunate and sad.” What’s unfortunate and sad is that employees of a college can’t do math or read .

Penn State faculty are right to oppose the wellness program on both ethical grounds and economic grounds. Their creativity on how affected faculty and staff should respond is applause-worthy. Entering bogus data on the HRAs (both legal and harmless to employees because HRAs are anonymous) and refusing to get any of the preventive care recommended are useful guerilla steps. They are also discussing a blanket refusal to participate, which means either everyone gets hit with the penalty or no one does.

A Modest Proposal: Replace the Med School Interview With fMRI

Aug 12, 2013• 9

By Tim Lahey, MD

A fashion faux pas almost prevented me from getting into my dream medical school. Midway through the interview there, the interviewer pointed to my left earlobe and said, “Do you really think we accept men who wear … those things?”

I had no idea what he was talking about at first, but then remembered the gold post I’d forgotten to remove. In a disdainful southern drawl the interviewer let me know how dark a shadow this stylistic error cast on my otherwise favorable application.

I left his office fairly sure I would not be admitted. I also doubted whether I wanted to be admitted to a school that selected physicians on the basis of their jewelry. Really?

Twenty years later, medical schools around the country still struggle to find the right way to decide who should be the physicians of the future, and who should not. Most have evolved past caring about male earrings, but what are the right criteria for admission – what makes a good proto-doctor?

Over forty thousand students apply to medical school each year. Each applicant spends thousand of dollars in fees and plane tickets, and institutions spend still more to screen, host, interview and pick among the hordes of black-suited applicants. Increasingly, medical schools are considering innovative and creative ways to distinguish the most promising applicants from the rest.

New approaches include:

1. Using a more holistic review rubric that de-emphasizes grades and MCAT scores, such as at Boston University;

2. Suspending traditional pre-med requirements for humanities students, such as at the Icahn School of Medicine at Mt Sinai; and,

3. Creative admissions interviews that include problem solving, multiple mini-interviews and even observed standardized patient interactions.

Each of these innovative methods sounds great. Used in combination I suspect they will identify applicants with the necessary academic chops plus a great bedside manner.

Why Congress Should Pass the Accuracy in Medicare Physician Payment Act

Aug 12, 2013• 4

By Brian Klepper & Paul Fischer, MD

With the recent release of two mainstream exposes, one in the Washington Post and another in the Washington Monthly, the American Medical Association’s (AMA) medical procedure valuation franchise, the Relative Value Scale Update Committee (RUC), has been exposed to the light of public scrutiny. “Special Deal,” Haley Sweetland Edwards’ piece in the Monthly, provides by far the more detailed and lucid explanation of the mechanics of the RUC’s arrangement with the Centers for Medicare and Medicaid Services (CMS). (It is also wittier. “The RUC, like that third Margarita, seemed like a good idea at the time.

For its part, the Post contributed valuable new information by calculating the difference between the time Medicare currently credits a physician for certain procedures and actual time spent. Many readers undoubtedly were shocked to learn that, while the RUC’s time valuations are often way off, in some cases physicians are paid for more than 24 hours of procedures in a single day. It is nice work if somebody else is paying for it.

Two days after the Post ran its RUC article on the front page, it reported that the AMA is already visiting Congress in force, presumably to protect its role defining the value of medical services for Medicare. The question now is whether Congress will take steps to remedy the situation.

Enabling the Health Care Locavore

Aug 11, 2013• 32

By Adrian Gropper, MD

Three juicy lemons came through my inbox this week. The NY Times published an expose of why hip replacement surgery costs 5-10 times as much in the US as in Belgium even though it’s the same implant. JAMA published research and a superb editorial on the Views of US Physicians About Controlling Health Care Costs and CMS put out a request for public comment on whether physicians’ Medicare pay should be made public. Bear with me while I try to make lemonade, locally, from these three sour economic perspectives.

Here’s a super-concentrated summary of the three articles: The hip surgery is more expensive because, in the US, as many as 10 intermediaries mark-up the price of that same hip prosthesis. Then, Tilburt et al said in JAMA that “physicians report that almost everyone but physicians bears responsibility for controlling health care costs.” The physicians reported that lawyers (60%), insurance companies (59%), drug and device manufacturers (56%), even hospitals (56%) and patients (52%) bear a major responsibility to control health care costs. Finally, CMS is trying to balance the privacy interests of physicians with the market failure that my other two lemons illustrate.

Can we apply local movement principles to health reform? How much of our money can we keep with our neighbors? What policies and technologies would enable the health care locavore? The locavore health system couldn’t possibly be more expensive than what we have now and, as with food and crafts, more of the money we spend would benefit our neighbors and improve our community.

Should Doctors Keep Patients’ HIV Status a Secret?

Aug 11, 2013• 53

By Lisa Fitzpatrick, MD

At my infectious-diseases clinic in Southeast Washington, I work with some of the city’s most indigent patients. Some don’t have jobs, a home, a car or enough to eat. But recently, I saw a patient whose problem made these issues seem trivial.

Dealing with fatigue, a cough and a fever for several months, this woman in her 40s had been evaluated by four internists. They had tested her for a variety of conditions but not HIV. Each had recommended rest, two prescribed antibiotics, and one suggested an over-the-counter cough medicine. Experiencing no physical relief from these suggestions, the woman had decided to “lay down and die.”

However, after her longtime partner insisted she get medical help, she agreed to go to a hospital emergency room. After a rapid test, which she initially refused because she said she was not at risk for HIV, she learned that she was HIV-positive.

After that ER visit, she brought her partner, whom she credits with saving her life, to my clinic to be tested; she was concerned that she had transmitted the virus to him. He tested positive. About a week later, when he accompanied her to an appointment with me, I asked if he had been seen by a doctor to discuss treatment. He said no and indicated that he wanted to establish care in the clinic.

When I asked if he had ever been on HIV drugs, he gazed at the medication chart and pointed out his previous regimen, a cocktail that contained indinavir. Because I and many other doctors stopped prescribing this medication a decade ago, I knew he had been keeping his condition from her for years. He stopped talking and avoided my gaze. It was clear he knew that I had learned his secret. I had many questions for him; but this visit was for her.

It was not the right moment to dredge up this history and ask how he could keep his diagnosis hidden while watching his partner struggle with her health. I chose not to ask about his dishonesty, their relationship and whether they had used condoms to protect her from getting HIV. At this point, I needed to help her understand that, even though she felt weak and sick, the medications would soon make her feel better. And that, with the right treatment, she could still live a long life.

While talking with my patient about her treatment, my mind kept wandering back to her partner’s secret. Was it my role to admonish him in front of her, or would that make things worse? What would they say to each other when they got home? I wanted to discuss these questions, but did I have a right to insert my judgment into this situation? At a private visit with me two weeks later, she let me know that this was the moment she realized he’d been keeping his diagnosis from her for years.

As a physician, I am not allowed to reveal any medical information about my patients or their circumstances without their written permission. This confidentiality is sacred. But in this case, that constraint felt inappropriate and irresponsible.

What the Recent Data Breach Says About the State of Health IT

Aug 11, 2013• 26

By David Do, MD

Recently officials at Oregon Health Sciences University discovered that residents in several departments were storing patient information on Google Drive, and had been doing so for the past two years. They treated this discovery as a breach of privacy and notified 3000 patients about the incident.

While I don’t condone the storage of patient information on unapproved services like Gmail or Google Drive, this incident pretty much highlights the sorry state of information systems within the hospital and the unfulfilled need by physicians for tools that facilitate workflow and patient care.

It says something that the Oregon residents felt compelled to take such a drastic action. I don’t know what punishment – if any – those responsible were given by administrators for their “crimes.” I’ll leave it to readers to make up their own minds about the wisdom of the unauthorized workaround and the appropriateness of any punishment. But I do know that the message the incident sends is a very clear one.

We’re screwing this up. There is really no earthly reason why it should be any more difficult to share a patient record than it is to share a Word doc, a Powerpoint or yes, even a cloud-based Google Drive spreadsheet.

Why the Breach Happened

What’s going on here? Let’s say I admit a patient to the hospital. Our friend was hospitalized here just last month, and like many patients, he has dementia or is poorly educated, and does not know the names of the medications he takes. Unfortunately, I don’t have the ability to see what he takes or how he was treated during the prior admission because the records in the computer are there for documentation’s sake and don’t contain any meaningful information. This is clearly a problem for me.

Therefore I will spend time calling outside facilities to gather information and repeat several tests and imaging procedures.

Medical care has become a team sport, and residents have developed systems for keeping track of their patients and communicating to other physicians. It takes some time to think about and process each patient that comes in, to consolidate all the information. Ultimately, I need to boil that information down to a five-minute description on the patient, their problems, the status of their current admission, and what needs to happen before they go home. We do this in the form of a signout document.

Figure: The signout document has four to five columns and includes the To Do list for each patient.

The EMR does not have a good way to store information in this format, and additionally I have no way of editing this in real-time to communicate with my
coworkers what still needs to be done. That’s why residents were storing their signouts in Google Drive.

What providers need here is simple data management. We need to store and access this list from different computers. We need the ability to enter a subset of those data using a custom form, and the ability to print subsets of those data to create a To Do lists, rounding sheets, or progress notes.Continue reading…

Health 2.0 EDU: The Shifting Value of Health Care with Kim MacPherson

Aug 10, 2013

The health care environment isn’t just changing for digital technology, it is also changing in education for instructors and professionals like Kim MacPherson, the Associate Director of UC Berkeley’s Center for Health Technology. Kim MacPherson will be joining forces with Health 2.0 EDU October 3rd, as part of a three-day executive education course on digital health, where she will share her insights as to how and why this changing environment is important to the value of health care:

EDU: Can you discuss the origins of the shift from volume to value in health care and why this concept is fundamental to the marketplace today?

KM: We have seen multiple attempts over the years to shift away from a volume mentality, but it has been thwarted in the past, in part by the lack of technology and actionable information to support value based efforts. Right now we are seeing an exciting convergence of economic and policy signals, a growing demand to prioritize value by employers and consumers, as well as acceptance by providers that change is inevitable. The focus on outcomes over volume and the new access to timely and more accurate cost and quality data makes the shift to a value focus possible on a larger scale than ever before.

EDU: In what key way is digital technology changing how the marketplace derives economic value in health care?

KM: For me it comes down to engagement, connectivity, and decision support: How to get the right parties meaningfully involved, make sure they have a clear pathway to follow to achieve the desired outcome, and are well supported with actionable information so the entire interaction creates value. This will involve a diverse range of technology including, tele-health, crowd-sourcing, digital diagnostic tools, protocol/pathway tools/simulations, stratification software, and consumer directed applications. We historically have seen a great deal of wasted time and resources when elements of this chain are not in place or are ineffective. The default to status quo is very easy in health care where there is a high degree of resistance to change by all stakeholders and where outcomes are not easily defined or agreed upon in advance. Digital technology enables change, making new processes and ways of improving health care delivery, financing and patient outcomes finally within reach.

EDU: How have some of the financial and research organizations you have consulted for best used digital technology to improve both outcomes and their bottom line?

KM: Lately I have been most interested in some of the digital technology aimed at consumer engagement; How do we get people involved in both their own health and their health care? Digital technology is being used by health plans and large employers that I work with to both promote wellness through “gaming” style competition applications and web-based technology that allows them to “shop” for the best services. The ability to personalize the experience seems to be a key dimension and a lever to promote real behavior change. Through these applications to digital technology, they hope to shift emphasis and resources toward prevention, improve worker productivity and satisfaction and over time, and see meaningful change in health as well as in their benefit costs.

EDU: How will this Health 2.0 EDU course differ from your usual classes at the UC Berkeley School of Public Health?

KM: In some ways it will be similar as I use a highly interactive format in both environments. The main difference is that I typically teach classes at Berkeley where digital technology is one facet of the overall course material vs. it being the focus. My areas of specialization involve health care finance, policy interpretation and understanding the incentives that drive a range of stakeholder behavior within health care. This course offers the chance to go a little deeper into this one key element: examining how some of these core health care areas touch and are impacted by digital technology.

EDU: What are you most looking forward to in your upcoming UC Berkeley course with Health 2.0 EDU, and what do you hope your students will take away?

KM: I am mainly looking forward to engaging with the diverse and dynamic participants. I love the energy and enthusiasm of Berkeley graduate students, but it is also stimulating to have industry professionals in a course, bringing their perspective and more immediate issues into the discussions. I hope that they get some economic and policy context that can stimulate new insights into their work. I also hope that being in an environment that fosters open interaction and exposure to material that may be new or unfamiliar, pushes them outside of their day-to-day roles and thought processes to consider different approaches and ideas to existing challenges.

Registration for the executive course ends September 1, 2013. The full agenda is available HERE.

Beyond the Affordable Care Act: A Framework for Getting Health Care Reform Right

Aug 9, 2013• 28

By Martin Gaynor

The following was drafted quite a few months ago, and had its genesis in a list of recommendations for improving the health care system that David Dranove solicited from a number of academics for an issue of Health Management, Policy and Innovation. I’ve dawdled in finishing and polishing it up, but seeing the stimulating reform proposal posted recently by Jay Bhattacharya, Amitabh Chandra, Mike Chernew, Dana Goldman, Anupam Jena, Darius Lakdawalla, Anup Malani and Tom Philipson motivated me to return and finish it; so here it is finally.

Introduction

One can hardly say that there’s been too little discussion of health reform recently. However, much of the discussion is focused on the ACA and its details. That’s fine, but we’ve gotten very far away from thinking about overarching principles that we think should guide the design of a health system, and what that implies for what it would look like [1]. What follows are some thoughts on what such a health reform might look like. They are informed by my read of the research evidence, and my observations of the U.S. health care system over a long period of time, but should be understood as representing only my personal opinions.

This is not intended as a criticism of the ACA. While the ACA certainly isn’t perfect, in my opinion we’re better off as a country with it than without it. However, there will be modifications to the ACA and other changes to the health system as we move forward, so having a framework to structure our thinking will be useful as we consider these inevitable changes.

Guiding Principles

What I propose below is guided by the following. First, economic efficiency is a goal. This simply means avoiding waste, i.e, trying to generate the maximum benefits net of costs. The second goal is that no American is exposed to excessive risk to their health or finances due to medical expenses. Last, the overarching design principle is to create basic ground rules for the system and then let the system run, avoiding heavy handed regulation or micro management. The key objective of these ground rules is to give participants the right incentives insofar as possible, while achieving insurance objectives. With that in mind, compassionate, efficient health reform would do the following.

Health Insurance Reform

First, eliminate the tax exclusion of employer sponsored health insurance. The exclusion of employer sponsored health insurance from income taxation distorts the demand for insurance. This leads to people with employer sponsored health insurance holding excessive coverage, which drives up medical spending and thus insurance premiums. Ironically, not taxing health insurance ends up making both health care and health insurance less affordable. Eliminating the tax exclusion of employer sponsored health insurance will eliminate a major distortion in health insurance, health care, and labor markets. It can generate substantial tax revenues (it’s estimated that the value of the state and federal income tax exclusion for 2009 was $260 billion[2]), while potentially allowing for lower income tax rates. It’s also worth pointing out that the subsidy is biggest for those who face the highest marginal tax rates, i.e., it’s regressive.

A Second Look at the Link Between Obesity and Mortality

Aug 9, 2013• 24

By Lua Wilkinson

A controversial study published earlier this year in the Journal of the American Medical Association shows that overweight people have significantly lower mortality risk than normal weight individuals, and slightly obese people have the same mortality risk as normal weight individuals.

This meta-analysis, headed by statistician Katherine Flegal, Ph.D., at the National Center for Health Statistics, looked at almost 100 studies that included 3 million people and over 270,000 deaths. They concluded that while overweight and slightly obese appears protective against early mortality, those with a body mass index (BMI) over 35 have a clear increase in risk of early death. The conclusions of this meta-analysis are consistent with other observations of lower mortality among overweight and moderately obese patients.

Many public health practitioners are concerned with the ways these findings are being presented to the public. Virginia Hughes in Nature explains “some public-health experts fear…that people could take that message as a general endorsement of weight gain.” Health practitioners are understandably in disagreement how best to translate these findings into policy, bringing up the utility of BMI in assessing risk in the first place.

Walter Willett, chair of the nutrition department at the Harvard School of Public Health, told National Public Radio that “this study is really a pile of rubbish, and no one should waste their time reading it.” He argues that weight and BMI remain only one measure of health risk, and that practitioners need to look at the individual’s habits and lifestyle taken as a whole.

The Strange Case of the C. Everett Koop National Health Award

Aug 8, 2013• 30

By Al Lewis & Vik Khanna

The late Dr. C. Everett Koop was the most revered Surgeon General in history, perhaps even the most revered Cabinet member. His calling card—indeed, his claim to fame – was his integrity. A Reagan appointee, he acted as though he reported to no one other than the American people and his own conscience. His penchant for candor and scientific independence fueled the federal government’s groundbreaking steps to raise public awareness about HIV/AIDS at a time when the tendency was to demonize and diminish. He resisted incessant political pressure and refused to take positions or produce data that he knew to be false.

This drew strong support from both sides of the aisle, and even his detractors never questioned his honesty. (Exhibit A: The two authors of this posting, whose political views have little else in common other than respect for strong, independent-minded politicians.)

Dr. Koop’s legacy stands in sharp contrast to the eponymous award dispensed by The Health Project, whose committee members have turned their back on their founder. The last thing Dr. Koop would have expected is to see is *his* award bestowed upon people who know that they don’t deserve it. The 2012 award was given to three recipients for work done in Nebraska: a vendor that claims wellness programs don’t even have to exist to save money, an outfit that can’t even spell the name of its own founder, and a state employee benefits plan that is under investigation for sky-high administrative costs.

Among the extravagant statements that formed the basis for the award (like claiming more than $20,000 in savings for every person who reduced their risk factors for a year, even though per-person spending is only $6,000), they claimed to have made 514 “life-saving catches” on employees with otherwise undetected cancer. This data was obviously wrong to begin with — that cancer rate would have been at least 40 times greater than Love Canal’s. Nonetheless, it sure sounded good, and the Governor of Nebraska himself was all-in too, so an award was issued.