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Looking for Interoperability in All the Wrong Places

Nov 8, 2011• 4

By Adrian Gropper, MD

To achieve interoperability, simply reduce the cost of interfaces. The economic value will follow.

Vendors, hospitals, patients and the states are all the wrong places to look for interoperability. Vendors prefer to lock-in their customers, differentiate their product and derive revenue from interfaces. Hospitals prefer to lock in their patients, differentiate their service and derive revenue from pricing power in the marketplace that results from consolidation. Patients confused by the technical nature of interoperability are easily misled into erecting privacy barriers that obscure quality and cost transparency. Finally, the states spend federal money designed to seed interoperability following established bureaucratic and political paths dominated by unchallenged input from vendors, hospitals and misinformed patients.

The cost of interfaces is the sum of Identity, Consent, Transport, Software and Opportunity. Reducing the cost of all five to near zero is possible and relatively easy. The Web and DICOM interfaces to radiology systems demonstrate many of the details at a large scale and for over a decade.

Identity can be free and easy if it’s voluntary to the person or system being identified. On the Web, identity is an email address. Email is free and available to all, even if they have to go to the library to use it. Email IDs are voluntary, you can use one or another as you choose without prejudice or permission. For a system example, DICOM interface IDs are IP (Internet Protocol) Addresses. They too are free and voluntary. The Direct Project is healthcare’s version of a free and voluntary ID for people and for systems. For both patient and clinicians, Direct Project identity is based on email addresses. Patients can already get a free Direct email ID from Microsoft HealthVault. Doctors can get one from Surescripts/AAFP for $15/month and free options are sure to follow. Free, voluntary identity eliminates one of the major costs of health information exchange: the Master Patient Index (MPI). MPI is one of those technologies that costs more the larger it gets. It’s time we abandon MPI as a path to interoperability.

The Michael Jackson Verdict

Nov 8, 2011• 3

By DOC GURLEY

It has been over two years and the tragedy of Michael Jackson’s death has finally been laid to rest. The verdict of accidental manslaughter highlights how dangerous medications of any kind can be. A couple of years ago I wrote about the events surrounding Michael Jackson’s death and tried to look at why Dr. Conrad Murray was being tried for manslaughter rather than some other charge like murder. I also took a look at what happened and how.

Now that the verdict is in, it looks like Dylan Schaffer was right and the verdict does match what we knew publicly. There are a great many lessons that can be learned from the whole saga, but the biggest one is that people really need to try to understand what the medications prescribed for them do, why they should and should not take them and most importantly, really know what the right dosages are. And please do not be fooled by the fact that the drug in question is a rare and powerful one that requires prescription and careful administration.

It is all too easy to die from taking simple over the counter medications in the wrong amounts and at the wrong time. And mixing and matching medications and other substances makes things worse. Probably the easiest way to get yourself in trouble with medications is something like getting a headache and the flu, taking a heavy dose of paracetamol, then a couple of stiff drinks and a big slug of something like Nyquil. Suddenly you are getting awfully close to liver damage or death.

What Difference Does Health Insurance Make?

Nov 7, 2011• 61

By John Goodman

Almost everyone thinks we should insure the uninsured. I don’t recall even a single dissenter. Yet it is precisely when everyone agrees on something that thinking begins to get very sloppy. So let me be the devil’s advocate and challenge the idea.

Why do we want to insure the uninsured? Forget about the costs, for a moment. Are there any benefits? What are they? I can think of four candidates. If people are insured:

They may get more health care.
They may get better care.
They will enjoy protection from the financial effects of catastrophic illness.
They will be less likely to be free riders on the charity of others.

The first three items are “it’s for his own good” benefits and, frankly, the case for them is pretty lame — especially in the context of RomneyCare and ObamaCare. If you expand the demand for health care but do nothing to increase supply, people in the aggregate will not be able to get more care. One person’s gain in care will be offset by someone else’s loss. (At least that tends to be the case, when the principal currency patients use to pay for care is time and not money.) Since the costs of non-price rationing will rise in the process, the whole exercise must make society as a whole worse off.

The same objection applies to the idea of “better care.” Better care for one person must be obtained at someone else’s expense, if the supply of medical resources is unchanged.

[I suppose you could make an additional argument: If we insure the uninsured, they will have a better chance of getting a “fair share” of health care. In other words, care will be distributed more equally. While that argument makes sense in the abstract, it doesn’t work if you segregate the previously uninsured into plans that pay providers below-market rates — as both RomneyCare and ObamaCare do — and cause them be pushed to the rear of the waiting lines. See below.]

The Fine Line Between Shared and Manipulated Medical Decisions

Nov 7, 2011• 7

By MICHAEL MILLENSON

Spend some time with the Society for Medical Decision Making, and “shared decisions” starts to seem less a clinical ideal and more an offshoot of picking a monthly cell phone plan. The fine line between “motivating” and “manipulating” behavior (albeit sometimes unintentionally) starts to blur.

At the group’s recent annual meeting in Chicago, the differing sensibilities of medical and marketplace ethics were in plain view on a panel entitled (with a nod to the Richard Thaler and Cass Sunstein behavioral economics best-seller), “From a Nudge to a Shove: How Big a Role for Shared Decision Making?”

Peter Ubel, a physician and a professor of marketing and public policy at Duke University, told how some free-market theorists have defined away, “overweight.” Since people know what causes them to put on pounds, goes this reasoning, the weight they are must be the weight they rationally decided to be. (Shades of Dr. Pangloss!)

Unfortunately, eating decisions are not purely rational. Eat in a large group, said Ubel, and lingering at lunch could boost your calorie count by 25 percent. Choose the large plate at the buffet table over the small one and bump up calories another 25 percent. Our brains even seek out the bad: give us two identical crackers, but label one as having a more “unhealthy fat,” and we’ll consistently pick it over the healthier-labeled cracker in a taste test.

E-mail from TEDMED

Nov 7, 2011• 1

By Lucas Merrow

It’s the kind of event where you might find yourself (as I did) seated between the Surgeon General and a Nobel Prize winner in Chemistry, with a singer/actor/model type across the table. Yet somehow, everyone finds common ground.

Once again, a who’s who of people descended on San Diego for TEDMED – three days packed with smart, provocative folks discussing how Technology, Entertainment, and Design play out in the healthcare field.

We’ve been attending TEDMED for a few years now, and this one might just be the best we’ve seen yet. From my perspective – an engineer at heart who’s devoted the past twelve years to growing a healthcare technology and communications company – TEDMED boiled down to this: the challenge of managing a range of increasingly complex systems, the need for collaboration, and a clear call to action to effect change.

We’re not kidding when we talk about complexity. A few highlights: Dean Kamen (one of my former bosses and current mentors) of Deka Research & Development and David Agus of the University of Southern California made their respective calls for a more responsive regulatory environment in the face of more complex and sophisticated medical breakthroughs, as well as an approach for documenting the social cost of not approving them. Eric Schadt of Mount Sinai School of Medicine described the dizzying complexity of genetics the way an engineer might model a network – think of a GPS for your DNA – helping even those (like me) who can’t grasp the genetic system understand how it works and how personalized medicines interact with it.

Crowd-sourcing Medical Bills

Nov 5, 2011• 7

By KATIE VAHLE

What if everyday purchases were priced and consumed like healthcare services?

These days you’d have to try hard not to know the price of a product or service before you buy it. So imagine booking an airline ticket with zero knowledge of the cost, only to return home to a bunch of outstanding bills for the trip. One statement may cover the seat rental and fuel used. Another bill may itemize each time the flight attendant handed out drinks. A few weeks later a bill for the pilot’s flying time may roll in. Can you imagine the resulting confusion, stress and angst?

I know it sounds absurd but this is the nightmare patients face every time they use the healthcare system. And it isn’t uncommon for these confusing medical bills to spiral out of control. Last year, the Commonwealth Fund (a non-profit healthcare research group) reported that 20% of US adults had medical debt or faced problems paying medical bills and only 58% of Americans felt confident they would be able to afford the care they needed.

So what options do consumers have when faced with the reality of paying for their healthcare?

Could a Pharmacy Monopoly Affect Your Healthcare?

Nov 5, 2011

By John Horton

Teddy Roosevelt, our swashbuckling 26th U.S. President, is probably best-known for his love of the environment and post-presidential African hunting tours. But today, two of his lesser-known but lasting legacies — antitrust law and ensuring that U.S. residents have access to safe medicines — are about to intersect in ways he couldn’t possibly have imagined.

Mention “antitrust” at a dinner party, and you’ll likely be drinking alone soon. But every time you choose which product to buy based on price, delivery times or other factors, you are benefitting from antitrust principles that originated with Roosevelt’s “trust-busting.” As president, Roosevelt saw that corporate monopolists — think Daddy Warbucks types — could, once they controlled the market, set prices as high as they’d like, or even use their market leverage to deny the supply of the same products to competitors. The result: everyday citizens, deprived of choice, would (quite literally) pay the price.

Roosevelt also championed the fight against medical snake oil salesmen, urging Congress to pass the first federal Drug Safety Act — the precursor to today’s FDA and its regulatory structure. Today, thanks to Roosevelt’s foresight, U.S. pharmacies set the global standard for prescription drug accessibility and safety.

But if you’re on a regimen of prescription drugs, you already know how expensive prescription drugs can be — and you may have found yourself comparing prices among pharmacies, looking for the cheapest deal, or trying to figure out which healthcare plan is least expensive for your needs. Here too, basic antitrust principles hold true: anti-monopolistic competition among America’s diverse pharmacies and healthcare plans is a good thing, and serves to drive down prescription drug prices, making medicines more affordable — and thus, available — to millions nationwide.

But what would happen to this diversity, and to patients, if one company — one pharmacy — were to engage in monopolistic behavior?

What if the Supreme Court Strikes Down the Individual Mandate?

Nov 4, 2011• 20

By D. Brad Wright

Any ruling by the Supreme Court on the constitutionality of the Affordable Care Act’s controversial individual mandate isn’t likely for at least another several months, but it’s worth thinking about what might happen after the case is decided. The first scenario is easy: If the Court upholds the mandate, the ACA goes forward as planned to the continued objections of many conservative Americans and politicians. The second scenario is less clear: If the Court finds the mandate unconstitutional, do they find it severable from the rest of the law? If not, they’ll strike the whole ACA down. This seems like the least likely outcome. If, on the other hand, they do invoke severability, the ball is back in the White House’s court. The decision at that point would be whether or not health reform can be successful without the individual mandate.

The concern here is the death spiral first described by Nobel Prize-winning economist Joseph Stiglitz. In essence, if we don’t require everyone to buy insurance, then insurance will be disproportionately purchased by the sick, making it more expensive and leading many to discontinue coverage in a continuous cycle that drives the price higher and higher until no one can afford insurance any more and the system collapses. By contrast, getting everyone into the pool is seen as the only way to keep costs down and maintain the insurance system. So the question is: What happens if the Supreme Court strikes down the individual mandate? Does the Obama adminsitration wash its hands of health reform, proclaiming that it can’t be done without the individual mandate because costs will rise too rapidly and the insurance system will collapse, or does it forge onward and see what happens?

Getting the Patient’s POV

Nov 4, 2011• 1

By JESSIE GRUMAN

One major challenge for the new Patient Centered Outcomes Research Institute (PCORI) is to make good on its stated mission to improve health care by producing evidence “that comes from research guided by patients, caregivers and the broader health care community.”

In order to “guide” that research, patients will offer their time and their experience to serve on various panels alongside scientists and other stakeholders, many of whom have competing agendas. This means that representing the patient perspective in research governance, priority-setting, design, execution and dissemination is not a good task for the shy or the ill-prepared. Not only do you have to have reflected on your own experience as a patient, but you have to have a good sense of how much you can generalize from that experience. This is, after all, not about you. It is about us – all of us patients.

Sometimes this means gathering information from others who have a similar diagnosis and who have been treated with similar approaches. What was getting chemotherapy for breast cancer like for you?

Sometimes it means learning about how people with different kinds of heart conditions or kinds of cancer experience their diagnoses and treatments or health care in general. What happened when you were discharged from the hospital?

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