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Transforming Diagnosis

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By Thomas Insel, MD

In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).1

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. Continue reading…

Could Opening Up the Doors to the World’s Medical Research Save Healthcare?

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By John Willinsky

What if you had access to all of the medical research in the world? Or better yet, what if the physician treating your particularly complex or rare condition had access to the latest research? Or what if a public health organization in your community could access that research to inform policymakers of measures to advance public health?

“Wait,” you may think, “can’t they already access that research? Doesn’t the Internet make that possible?” While unfortunately the answer to the first question is “No,” fortunately the Internet can make such access possible. As it is today, most physicians and public health professionals have very limited access to health research, almost all of which is published online. Only about a quarter of the research published today ends up being available to those working outside of universities, where libraries subscribe to a good proportion of the research journals.

So, what are these health professionals missing? What difference to their work would access to research make? Cheryl Holzmeyer, Lauren Maggio, Laura Moorhead and I seek to answer these questions with a new National Science Foundation study for which we are currently recruiting physicians and staff of public health NGOs.

We seek to demonstrate the difference it makes to the daily work of these health professionals to have easy electronic access to all the biomedical and public health research – or at least that large proportion held by Stanford University Library – for a period of eleven months (with one month of limited access as a control). To assess the impact of this access, we provide participants with a special portal to the research literature and track when and what research is viewed, while following up with interviews on the use and value of this access.

Continue reading…

Box Picking Up Where Google Health Left Off

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By Missy Krasner

You probably saw some of the headlines last week where Box announced that is supporting HIPAA and HITECH compliance, signing Business Associate Agreements, (BAAs) and integrating with several platform app partners such as  Doximity, drchrono, TigerText, and Medigram to help seed its new healthcare ecosystem.  I also announced that I was formally advising Box on their healthcare strategy.

I was drawn to Box because of all the lessons I learned at Google building a consumer-directed, personal health record (PHR), Google Health. Google Health allowed you to securely store, organize and share all of your medical records online and control where your data went and how it was managed. It was unlike the other PHRs in the industry that were tethered to the provider or payor or part of an Electronic Health Record (EHR) system.

Sound good? Well, it was in theory. The big issue with Google Health was aggregating your data from the disparate sources that stored data on you.  We had to create a ton of point-to-point integrations with large health insurance companies, academic medical centers, hospitals, medical practices and retail pharmacy chains. All of these providers and payors were covered entities in the world of HIPAA and were required to verify a patient’s identity before releasing any data to them electronically. It was a very bumpy user experience for even the most super-charged, IT savvy consumer.

Continue reading…

Misunderstanding Oregon

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By Ashish Jha, MD

Much has already been written about the Oregon Medicaid study that just came out in the New England Journal of Medicine. Unfortunately, the vast majority is reflex, rather than reflection.  The study seems to serve as a Rorschach test of sorts, confirming people’s biases about whether Medicaid is “good” or “bad”.

The proponents of Medicaid point to all the ways in which Medicaid seems to help those who were enrolled – and the critics point to all the ways in which it didn’t.  But, if we take a step back to read the study carefully and think about what it teaches us, there is a lot to learn.

Here is a brief, and inadequate, summary (you should really read the study):  In 2008, Oregon used a lottery system to give a set of uninsured people access to Medicaid.  This essentially gave Kate Baicker and her colleagues a natural experiment to study the effects of being on Medicaid.

Those who won the lottery and gained access were compared to a control group who participated in the lottery but weren’t selected.  Opportunities to conduct such an experiment are rare and represent the gold standard for studying the effect of anything (e.g. Medicaid) on anything (like health outcomes).

Two years after enrollment, Baicker and colleagues examined what happened to people who got Medicaid versus those who remained uninsured.  There are six main findings from the study.  Compared to people who did not receive Medicaid coverage:

  1. People with Medicaid used more healthcare services – more doctor visits, more medications and even a few more ER visits and hospitalizations, though these last two were not statistically significant.
  2. People with Medicaid were more likely to get lots of tests – some of them probably good (cholesterol screening, Pap smears, mammograms) and some of them, probably bad (PSA tests).
  3. People with Medicaid, therefore, not surprisingly, spent more money on healthcare overall.

    4. Continue reading…

It Was the Best of Times, it Was the Worst of Times

By Matthew Holt

Optimized-EdisonAt Health 2.0 we have a natural bias toward the innovator, the entrepreneur, and the developer. Health care is largely broken, and those upstarts have the potential to fix it. But it’s by no means easy. Part of what we’re doing at our upcoming Health:Refactored conference is helping developers get access to APIs and other technical entrees into health care data (such as the SHIN-NY or HealthVault).

But as Paul Levy pointed out in a recent post about Epic’s domination of the large hospital system EMR market, and as Jonathan Bush hilariously detailed in a talk at last week’s TEDMED, health care’s money and data and power are still locked up in huge institutions that don’t have it in their business plans to give up that position — whatever their mission statements might say.

Francois de Brantes’ book The Incentive Cure details in a fun way how hard it is for providers to do the right thing, and how in the absence of changing incentives, most of the things that seem to make sense for better health (like holistic patient management, care variation reduction, better informed patients and providers) actually make worse sense for health care institutions. Which means that the dam is still holding back the torrent of ideas and solutions from innovators, entrepreneurs and developers. We know (broadly) what to do but we can’t do it. It’s the worst of times.

But two things are changing. One is that we at least recognize the problem. The system may be an addict, but it knows it’s one, and so does the taxpayer and the patient. So that first step has been taken. The second change is the flood of new technologies outside of, and now inside of health care, that can help us get through the next 11 steps. Todd Park says this is the best time ever to be a tech entrepreneur in health care. So is this the best of times? Eventually it’s up to all of us to make it so.

Evidence That Health Does Not Equal Healthcare? Early Results From the Oregon Experiment Are In

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By Mike Miesen

The most important study in American health policy in decades, the Oregon Health Insurance Experiment, published two-year results Wednesday in the New England Journal of Medicine. If you’re reading up on the topic, get ready for bombastic claims and scorching heat as opposed to illuminating light. The quick read leads to an easy Drudge headline – “MEDICAID DOESN’T MAKE PEOPLE HEALTHIER: OBAMACARE WILL FAIL!” – but a fuller reading of the evidence provides a more optimistic, and honest, take.

In 2008, Oregon had 90,000 individuals who wanted to enroll in its Medicaid program, but the funding to enroll only a fraction. So it decided to use the opportunity to create an unparalleled experiment: the first Randomized Controlled Trial (RCT) – the gold standard research methodology that is able to isolate the causal effect of an intervention – in Medicaid history. It endeavored to show nothing less than the actual, causal effect that Medicaid has on its population, a first in the field.

This study, in other words, is a big, big deal.

Two years of data are in, and the results are mixed. First up, the disappointing: Medicaid coverage.

Continue reading…

Obamacare’s Birth Control Mandate: The Most Controversial Legislation Ever?

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By Dan Diamond

The war over the Affordable Care Act may be over, but one battle shows no signs of waning.

The fight over Section 2713 of the Public Health Services Act under ACA’s Section 101 — better known as the health law’s regulation on preventive services — centers on contraception.

The benefit essentially calls for health plans to cover birth control and other services with no additional cost-sharing for enrollees.

But critics quickly seized on the administration’s initial proposal in 2011, which carved out an exception for “religious employers” — such as churches — but not for “religiously affiliated” employers — such as Catholic hospitals. As a result, HHS delayed implementation for religiously affiliated employers by a year but still required them to comply with the mandate.

In February, the White House released another accommodation for religiously affiliated employers. Yet rather than lay the issue to rest, the administration’s proposed amendments drew more than 400,000 comments — the most comments on any government regulation tracked by the Sunlight Foundation.

It’s just the latest salvo in an ongoing controversy. Opponents have filed more than 60 legal challenges against the benefit. Some have called it a “war on religion.”

While the sheer volume is astounding, there’s little mystery behind the root cause.

The contraception benefit touches on a half-dozen pressure points: Politics. Religion. Sex. Federal mandates. Federal entitlements.

“Our health care system is the dumping ground for all of our worst, unresolved arguments as a society,” J.D. Kleinke writes at The Health Care Blog. And the changes at the heart of Obamacare “spark every remaining culture war,” he adds.

And a mandate related to birth control is especially fraught.

Continue reading…

Attend New York Digital Health Accelerator’s First Demo Day

NYDHANine months ago New York Digital Health Accelerator‘s program began. Now it’s time for demo day, when eight companies get to show off their progress to date. NYDHA is run by the Partnership Fund for New York City and the New York eHealth Collaborative and was designed for growth-stage companies developing products for providers and patients in the care coordination, patient engagement, and health care analytics fields.

Who: NYDHA’s first class of eight companies:

ActualMeds’ software supports team-based medication management and reconciliation for high risk patients taking multiple drugs to reduce their drug related hospitalization and readmissions.

Aidin helps patients make the right choice of post-acute care providers by providing them with ratings and reviews on local rehab centers and nursing homes.

Avado partners with healthcare businesses to provide a platform that allows clinicians and patients to securely communicate, track, and manage health information.

Continue reading…

Fact Check:Will Increased Longevity Bring Down Medicare?

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By Richard Kaplan

The Sound Bite:

Increased longevity costs will bankrupt medicare.

Fact or Fiction?

This is partly fact, partly fiction. Medicare entitlement begins when a person ages in at 65, however just because beneficiaries are living longer does not necessarily mean higher Medicare costs.

The customary formulation of this myth is that Medicare is doomed by its own success in keeping its beneficiaries alive. Not only will the ranks of the program’s beneficiaries increase as the vaunted baby boom generation reaches the statutory age of eligibility, but because people are staying alive longer, Medicare’s costs will explode. The first part of this contention is indisputably true: entitlement to Medicare occurs when a person reaches age sixty-five, and the baby boom generation that is generally calibrated as starting in 1946 has arrived at that threshold. As a result, additional Medicare beneficiaries enter that program every day, and because the baby boom generation dwarfs any preceding age cohort, it is highly likely that more beneficiaries will be added to the program than are lost as older beneficiaries pass away. Consequently, the number of Medicare beneficiaries will inexorably increase over the next decade or so. Ceteris paribus, more beneficiaries mean higher aggregate costs.

The second part of the contention, however, is myth. Just because today’s Medicare beneficiaries live longer than did their predecessors does not necessarily translate into higher costs for the Medicare program. The source of this apparently counterintuitive proposition is the panoply of programmatic limitations that Medicare imposes on its coverages, regarding the myth that Medicare pays for long-term care. More specifically, beneficiaries who live longer typically do incur higher cumulative health care costs over their post-sixty-five lifetimes, but many of those costs are not borne by the Medicare program. This phenomenon is well illustrated by the following graph from an important analysis that appeared in The New England Journal of Medicine:

FIGURE 1: Cumulative Health Care Expenditures From the Age of 65 Years Until Death, According to the Type of Health Service and the Age of Death


Continue reading…

How to Find a Neurosurgeon On Craigslist

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By COLIN SON, MD

An uninsured Seattle man has put out an ad offering to trade his 2006 Mustang GT for brain surgery. He provides an image from a MRI of his brain even. The poster doesn’t describe what symptoms he attributes to his arachnoid cyst but the relationship between arachnoid cysts and late symptoms is often difficult to establish.

Arachnoid cysts have been associated with headaches, nausea, seizures, vertigo and even in anecdotal cases with psychiatric symptoms or the onset of dementia. But the relationship is often hard to establish. Up to a third of people with chronic headaches have some sort of abnormality on there MRI, including arachnoid cysts. Relating the findings and the symptoms is often difficult; sometimes you have a finding on an MRI or a CT scan but it is a red herring as far as the symptoms are concerned.

Arachnoid cysts are collections of cerebrospinal fluid trapped between the brain and spinal cord and the arachnoid membrane. They’re primarily a congenital entity but can be associated with trauma, infection or be iatrogenic following surgery. The vast majority of cysts are discovered incidentally and associated with no major symptoms. While even asymptomatic cysts can progress to cause symptoms and they can be associated with post traumatic, or even spontaneous, hemorrhage the risk of such is low enough that in small asymptomatic cysts it is often more than reasonable to do nothing.

I’m a little bit dubious of the poster as he relates that he’s been thinking of trying to get to the cyst himself. However, if it’s an honest post I think the poster really needs to sit down with a neurosurgeon in consultation and go over the above in detail and discuss the best course of action.

I suppose health insurance is coming in 2014.

Colin Son, MD is a neurosurgical resident in Texas. He blogs regularly at Residency Notes, where this post originally appeared.

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