The Health Care Blog – Page 635 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

How Much Weight Should Anecdotes Really Have In Health Policy?

May 23, 2012

By D. Brad Wright

There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they discover that their son or daughter is affected by it. Then, almost overnight, they seem to care more about issue Y than almost anything else. Such a shift is completely understandable, but often out of proportion to the true scale of the issue in society.

In health policy, the personal narrative can also be very powerful. In fact, the journal Health Affairs routinely runs a “Narrative Matters” section that puts a face on the health care issues of the day. It is absolutely critical that health policymakers, health services researchers, and others, not lose sight of the fact that their work and the subsequent decisions it informs, are based on real people. However, it is equally critical for objectivity to be maintained, and narrative can threaten our work in this regard.

Should the States Set Up ObamaCare Exchanges?

May 23, 2012• 4

By John Goodman & Linda Gorman

Under the Patient Protection and Affordable Care Act (PPACA), state governments are expected to set up health insurance exchanges through which individuals will buy their own health insurance, in many cases with substantial subsidies. Should the states comply?

In the following point-counterpoint discussion, Linda Gorman and I give opposing answers to this important question. Leave your thoughts in the comments.

John Goodman: Yes

If the states abdicate their responsibilities under PPACA, the federal government will step in and act in lieu of the state. Under this scenario, states will relinquish all power to make a bad law better. Letting the federal government implement reform almost guarantees bad outcomes.

Linda Gorman: No

Exchanges are required to perform a variety of duties beyond distributing ObamaCare subsidies, and these duties are likely to add significantly to estimated costs. Some of them will damage a state’s business climate by creating new opportunities for crony capitalism. Some require that currently fashionable, but poorly tested, models be forced on health care providers. Some require that state exchanges have expertise equal to private insurers. Others force states to increase the cost of health insurance for people who currently have coverage.

John Goodman continued:

The states should engage in preemptive reform over the next two years. This means enacting responsible, rational reforms — the kind of reforms that they should have enacted all along, in the absence of federal legislation. Where possible, states should try to make their reforms compatible with the new federal law — but only if compatibility does not sacrifice the major goals of the state’s reform.

Medicare Advantage Star Ratings: Detaching Pay from Performance

May 23, 2012• 5

By Douglas Holtz-Eakin

Rewarding quality health plans is an admirable goal for the Medicare Advantage program. Unfortunately, the current system of linking star ratings to bonus payments and rebate adjustments instituted by the Patient Protection and Affordable Care Act (and expanded by the CMS Quality Bonus Payment Demonstration) fails to achieve that goal, and depending on its specific implementation, may even be counterproductive.

Because criteria for evaluation are not published until after the period for which performance will be evaluated, there is no possibility that MA plans will be able to improve their performance to achieve the goals CMS intends to incentivize. Any adjustment plans will be able to make to their bids or plan offerings would have to be aimed at increasing enrollment in counties with the highest bonuses and rebates based on data from performance in previous years, possibly at the expense of improving their performance in the future.

The system rewards beneficiaries for choosing those plans favored by the selected CMS criteria, rather than the plans that best meet their needs. In effect patients whose preferences, health status, and even counties of residence, don’t match the CMS model of a highly rated plan will be at a disadvantage. Simultaneously, the system will likely reduce the scope of choice available to MA-eligible beneficiaries, and reduce competition among MA plans.

Finally, the system rewards beneficiaries for living in counties with low poverty rates (since relatively wealthier counties tend to have more plans with higher ratings), thus adversely impacting poor beneficiaries even more than non-poor beneficiaries.

These impacts are inconsistent with the overall policy purpose. The goal of incentivizing quality health plans is legitimate and admirable; that goal will not be achieved by the rating structure currently being put into place.

USPSTF – It’s About Time

May 23, 2012• 1

By Merrill Goozner

The numbers are stark. According to the United States Preventive Services Task Force, for every man whose death from prostate cancer is prevented through PSA screening, 40 become impotent or suffer incontinence problems, two have heart attacks and one a blood clot. Then there’s the psychological harm of a “false positive” test result, which is 80 percent of all “positive” tests. They lead to unnecessary worry, follow-up biopsies, physical discomfort and even harm. Final grade: D.

Three men close to me have been diagnosed with prostate cancer late in life. Each was around 70. My dad, already in throes of advancing Alzheimer’s disease, did what the doctor ordered (actually, I suspect my mom told my dad to do what the doctor ordered). He had surgery. And for the last six years of his life, which until his final three months was at home, she cleaned up after him because of his incontinence. My neighbor made the same choice. He quietly admitted to me one day that he suffers from similar symptoms, but he is grateful because he believes his life was saved by the operation. And my friend Arnie? I’ve written about him in this space before. He was diagnosed at 70, and being a psychiatrist with a strong sense of his own sexual being, understood the potential tradeoffs. He decided to forgo treatment. He died a few years ago at 90. I never learned the cause.

So what does it mean that PSA testing gets a D rating?

Sex Sells (or at Least Leads to Some Interesting Analytics)

May 21, 2012

By John Moore

One guarantee in the healthcare sector is that when it comes to personal health information (PHI), there is no lack of issues and pundits to discuss security and privacy of such information/data. If one does not jump up and down bleating on about the sanctity of PHI and the need to protect it at all costs, well then you may be labeled a heretic and burned at the proverbial stake.

Now don’t get us wrong. Here at Chilmark Research we firmly believe that your PHI is arguably the most personal information you have and you do have a right to know exactly how it is used. Whether or not you own it remains to be seen for we have seen, read and heard one more than one occasion – some healthcare providers believe that it is their data, not yours, and may only begrudgingly give you access to some circumscribed portion of your PHI that they have stashed in their vast HIT fortress, or worse, scattered in a number of chart folders.

But where we do differ with many on the sanctity of PHI is that the collective use of our de-identified PHI on a community, regional, state or even national level can give us some amazing insights into what is working and what is not in this convoluted thing we call a healthcare system in the US and needs to be strongly supported. Unfortunately, we do a terrible job as a country in educating the populace on the collective value of their data to understand health trends, treatments and ultimately ascertain accurate comparative effectiveness. This leaves the door wide open for others to use the old FUD (fear uncertainty and doubt) factor to keep patients from actively sharing their de-identified PHI.

New York Digital Health Accelerator: Last Call for Applications

May 21, 2012

By Matthew Holt & Austin Cohen

Just recently, the New York eHealth Collaborative and the New York City Investment Fund held an awesome information session for the New York Digital Health Accelerator at the chic digs of the TimesCenter in NYC. The Accelerator is a program for early — and growth — stage digital health companies that are developing cutting-edge technology products in the areas of care coordination, patient engagement, analytics and message alerts. The event was open to the public and provided thorough detailing of the accelerator, insights as to the types of solutions that participating providers hope to receive and – of course – some networking. If you missed this exciting event, you can check out the recorded stream. If you are interested in the program, access the application.

Twelve companies will be invited to participate in the nine-month program. A review committee — comprised of hospital leadership, technology experts, clinicians and investors — will select the companies. The committee will evaluate applicants on their product innovation in the four focus areas, the track record of their management team and their company life-cycle stage.

How Bad Is Azithromycin’s Cardiovascular Risk?

May 21, 2012• 9

By Dr. Wes

The paper from the New England Journal of Medicine that reports azithromycin might cause cardiovascular death is not new to electrophysiologists tasked with deciding antibiotic choices in patients with Long QT syndrome or in those who take other antiarrhythmic drugs. Heck, even the useful Arizona CERT QTDrugs.org website could have told us that.

What was far scarier to me, though, was how the authors of this week’s paper reached their estimates of the magnitude of azithromycin’s cardiovascular risk.

Welcome to the underworld of Big Data Medicine.

Careful review of the Methods section of this paper reveals that “persons enrolled in the Tennessee Medicaid program” were the subjects, and that the data collected were “Computerized Medicaid data, which were linked to death certificates and to a state-wide hospital discharge database” and “Medicaid pharmacy files.” Anyone with azithromycin prescribed from 1992-2006 who had “not had a diagnosis of drug abuse or resided in a nursing home in the preceding year and had not been hospitalized in the prior 30 days.” Also, they had to be “Medicaid enrollees for at least 365 days and have regular use of medical care.”

Hey, no selection bias introduced with those criteria, right? But the authors didn’t stop there.

Z-Packing

May 21, 2012• 2

By Rob Lamberts, MD

It was during my residency that the first indication of heart toxicity of antibiotics affected me personally. The threat was related to the use of the first of the non-drowsy antihistamines – Seldane – in combination with macrolide antibiotics, such as Erythromycin causing a potentially fatal heart arrhythmia. I remember the expressions fear from other residents, as we had used this combination of medications often. Were we killing people when we treated their bronchitis? We had no idea, but we were consoled by the fact that the people who had gotten our arrhythmia-provoking combo were largely anonymous to us (ER patients).

Fast forward to 2012 and the study (published in the holy writings of the New England Journal of Medicine) that Zithromax is associated with more dead people than no Zithromax. Here’s the headline-provoking conclusion:

During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002). Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. (Emphasis Mine).

Continue reading…

FOO For Thought

May 21, 2012• 11

By MARYA ZILBERBERG, MD

I cite this favorite quote from Max Planck in my book (and every chance I get):

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.

I think this applies to all walks of life, not just science. Yet sometimes an argument so compelling comes along that, though reluctantly at first, one by one the old guard drop at its feet. This is what happened to me this weekend at the Health Foo Camp in Cambridge, MA.

First, what is Health Foo? Well that was my first question when I received an invitation to attend this strangely named meeting. A Foo Camp is something put together by O’Reilly, the pioneering digital media group. Started 12 years ago, these meetings are thematic gatherings of “Friends of O’Reilly,” hence “Foo,” intended to bring together a diversity of thought about a specific field. The camp that I attended was the second such gathering in the healthcare space, supported in part by the Robert Wood Johnson Foundation, and held at Microsoft’s New England Research and Development Center in Cambridge. How can I ever thank O’Reilly, RWJF and Microsoft for this mind-shifting event?

As I mentioned in my previous post, the attendee roster was so full of luminaries that I frankly wasn’t sure that the invitation had not ended up in my Inbox by mistake. But mistake or not, what a privilege to attend! I spent the weekend getting to know the faces and the substance behind such familiar names as Regina Holliday, Paul Levy, Alan Greene, Ted Eytan, Susannah Fox, Gilles Frydman and others. And what still has my mind spinning is my conversations with people I don’t normally interact with — computational scientists, game designers, food advocates and international public health movers and shakers.

The most risky aspect of this meeting was the very essence of its success: we were to free-range. No agenda was set; space, food and company were provided. The resulting sessions ran the gamut from the usual nerd porn of probability to such far-reaching topics as memory and the role of faith, poetry and the arts in medicine (my personal favorite, where I got to play in the sandbox of participatory painting led by Regina. Take that, left brain!)

I have to say I spent a part of the weekend in a bit of a fog. What is gamification of medicine? What does “deep modularity” mean? But the full impact of such diversity of knowledge did not hit me until I was heading West on the Turnpike away from the meeting in the direction of home. It felt like a deep air pocket, and for a moment I couldn’t catch my breath.Continue reading…