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From Jeopardy! To Your Physician’s Black Bag: Could a Supercomputer Really Assist With Health Care?

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By DAN PELINO


IBM’s Jeopardy-champion computer, Watson, has huge potential for helping physicians and other clinicians work with patients.

The leap from TV game show to physicians’ offices will probably take at least two years. But Watson’s understanding of natural language, vast storehouse of information and ability to keep up with rapidly changing medical research could significantly improve medical care.

The medical faculty at Columbia University and University of Maryland are helping program a Watson-type computer to assist clinicians.

A few years from now, consulting Watson could become a routine part of a clinician’s practice. Caregivers have traditionally resisted computerized assistance in diagnosis and treatment because the technology has been awkward to use and questionnaire-based systems have been too rigid. But Watson can “understand” descriptions of a patient’s symptoms in natural language, and it can even scan years of medical records and doctors’ notes to determine what diagnostic and therapeutic options it might suggest. Doctors can ask it questions using the same terms they would use in an e-mail to a colleague. Continue reading…

Maine Waiver Expected to Increase Insurer Pressures on States

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By ROGER COLLIER

HHS’s bellwether decision of last week to grant the State of Maine a three-year waiver from the medical loss ratio provision of the ACA may lead to new efforts by insurers across the country to persuade states to demand similar waivers.

The HHS decision on Maine was not unexpected. The ACA language clearly allows for waivers when imposition of the MLR 80/85 percent threshold penalties would lead to disruption of a state’s insurance market. Maine, a state with very few major employers, has a higher than average percentage of small group and individual policies which typically provide higher out-of-pocket costs—and consequently higher administrative percentages. HealthMarkets, one of the two dominant insurers in Maine, had threatened to abandon the state’s individual market unless a waiver was granted. (According to a Bloomberg report, HealthMarkets, which is majority-owned by two large investor funds, was recently sued by the City of Los Angeles for selling policies with provisions that allegedly effectively eliminated needed coverage.)

Three other states (Kentucky, New Hampshire, and Nevada) have already filed waiver requests with HHS, and an additional eleven states are reported to be preparing waiver requests.

Almost certainly, every insurer with significant business in the small group and individual markets will be eying the Maine waiver decision with a view to applying pressure to those state insurance regulators who are not yet preparing waiver requests. While Maine appears to have had an unusually strong case for a waiver, the absence in the ACA of any specific measures for “market disruption” may make it difficult for HHS to reject such requests.

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies.  He is editor of Health Care REFORM UPDATE.

Medicaid and (supposed) Welfare Dependence

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By HAROLD POLLACK

Jonathan Cohn has a piece on Medicaid yesterday with which I agree. I want to amplify one related point.

National Review and Forbes writer Avik Roy believes that Medicaid is a “humanitarian catastrophe” which is actually worse than no insurance at all. Now Scott Gottlieb has taken up the argument in the Wall Street Journal. I’ve noted before that this is a bad argument. Medicaid should certainly provide better coverage. I’d also like to see the new exchanges provide poor people with better options outside of Medicaid. Yet the claim that people would actually be better off uninsured than they would be with Medicaid—this strains credulity.

I’ve basically said my piece regarding the causal impact of Medicaid in various studies. I want to pick up a different aspect of this debate.

Roy’s response to my initial column includes the following:

Many of the factors Harold raises as flaws of the study are actually flaws of Medicaid. It’s Medicaid that restricts access to the best hospitals and the best doctors and the best treatments. It’s Medicaid, i.e., welfare dependency, that leads to family breakdown and social disrepair. (For those who seek a more extensive discussion of this problem, read Charles Murray’s landmark book, Losing Ground: American Social Policy 1950-1980.)

I took umbrage at that, as indicated below. Roy then took umbrage at my umbrage, writing:

One aspect of Harold’s post is wholly unjustified, and a bit of a cheap shot: his assertion that I am “disrespectful” and “disparaging” to welfare recipients, because I’ve highlighted the corrosive effects of welfare dependency (something Harold dismisses as a “bromide”). We’ll never have a constructive debate on Medicaid policy if we can’t get past this kind of nonsense. The entire point of my series of posts on Medicaid is that Medicaid beneficiaries are the victims of an uncaring and bureaucratic system, and also the victims of those who, for ideological reasons, ignore the very real problems that Medicaid has.Continue reading…

A Speed Bump on the Road to Meaningful Use

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By MARGALIT GUR-ARIE

Meaningful Use has hit a speed bump. It’s of the low, wide and gentle type, not the old raggedy, narrow and mean bump you find in older parking lots. Now that a tentative proposal for Meaningful Use Stage 2 has been published by ONC, and duly commented upon by the public, it just dawned on folks that there isn’t enough lead time between Stage 1 and Stage 2 to allow for an orderly transition, and here is the problem in a nutshell.

Meaningful Use is divided into three, increasingly more demanding, stages, starting in 2011 with Stage 1 and advancing every two years to a higher Stage. So 2013 marks the beginning of Stage2 and 2015 is the start of Stage 3. It seems that ONC and CMS need about a year and a half to define each Stage from start to finish, so if they start working on Stage 2 right after Stage 1 commences, there are only 6 months left for NIST to define certification criteria, EHR vendors to update their wares and certify them, and physician and hospitals to roll the new and improved products out. Oops……

The hand wringing in “industry experts’” circles began immediately after this realization, culminating with an Advisory Board publication advising hospitals in particular to not apply for Meaningful Use incentives in 2011, but instead wait for 2012, which they can do without penalty, and the same advice is applied to ambulatory practices owned by hospitals. They did not recommend anything for physicians in private practice. Continue reading…

A Doctor is Not a Bank

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By KEITH W. BOONE

All too often I’ve heard the comparison between the financial industry and its efforts to make transactions electronic, and the healthcare industry.  But health is not something that I can make deposits on and withdraw later.  We aren’t talking about a case where there are only two organizations completing business transactions on behalf of their customers.

There’s a lot more going on here.  A better comparison would be to automation supporting electronic commerce between multiple businesses.  I’ll use electronic publishing as an example, since I have some history in that space.

Imagine that you had a customer needing a new web page.  You have to understand what the customer is trying to accomplish, and then design a page to meet their needs. Along the way, you have to obtain assets:  Text content, media (pictures or video), put it together, get approvals, and publish the content.  Obtaining the assets might involve negotiating access to content from others, paying someone to provide it, or simply assigning the job of creating it to someone on your staff.  Afterwards, you need to put all those pieces together into a coherent whole, possibly get someone to review and approve it, and then it gets pushed out to the web.  Anywhere along the way you may learn that there are other tasks to perform.  Some of the content may need to be coded in Flash, in which case, you might need to put a flash player download button on the site (which means you need another piece of content), et cetera. Oh, and if you are providing full service, you might also evaluate how people respond to the page, and make any adjustments necessary to improve their response.  Now, consider making that whole process electronic, and you begin to understand the complexity of healthcare. BTW:  There are systems that support this process electronically, but they are proprietary.Continue reading…

Catching Babies? JD Kleinke talks (well, IMs)

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By Matthew Holt

JD Kleinke has been one of my favorite people in health care for at least a decade (or probably more!) notwithstanding his barrages at all and sundry (sometimes including me) on this very blog. He’s been a little quiet of late, but that silence is over. He’s out with a new novel called Catching Babies. It’s a topic I’m thinking about a lot! As you may know I’m less than 2 months from being a first time dad, and Indu (my Health 2.0 partner) is similarly close to being a first-time mom. Both me and my wife read Catching Babies in pre-publication and it’s a tour de force of health policy and medical soap opera–Health Affairs meets Grey’s Anatomy–wrapped up in the complex world of childbirth. Now the book is out and we’ll be having JD at the  Health 2.0 Spring Fling in San Diego in a fireside chat about the book with Amy Romano (@midwifeamy). but I thought I’d take the chance to interview JD about the book and his previous and next steps. Here’s a (heavily edited) version of our IM chat–Matthew Holt

Matthew: You’re well known to THCB readers as a medical economist, policy wonk, and health IT entrepreneur geek from way back.  The obvious first question – why a novel of all things?  Does your shift to fiction imply that you’ve lost touch with reality?

JD: Lost touch? That would imply that I was ever in touch with reality in the first place!  You may recall that my very first book tried to argue that managed care was a necessary evil for the good of us all, including providers.  That the harshness of commercial managed care was the change agent we needed to get hospitals and physicians to modernize. I suppose that turned out to be fiction as well!

Matthew: OK so you’ve always been a bit of a dreamer, I might say the same thing about the health care IT ventures you’ve been involved with. But some of them, like Solucient and HealthGrades, are now pretty successful!  And Catching Babies is not just a novel – it’s a great story – but it also has more powerful things to say about a dozen health policy problems than as many treatises on the exact same subjects.

JD: Thanks for the kind words about the story, and if that’s true, it’s powerful as a policy document precisely because it is a novel.  For better or worse, this is how all of us, as human beings, relate to even the most abstract health care policy, or new technology, or business idea.  Every health policy is ultimately a patient, and every patient is ultimately a story.  Medicare coverage is extended for a new treatment because a Congressman’s mother once needed it. The crazy quilt of health benefits mandates at the state level exist because someone in each of those states got sick, was stuck with the bills for treatment, and took his case to the state senate either directly, or via the front page of the largest Sunday paper in his state. If you look back at the news building up to the passage of health reform, you’ll see that public opinion probably crested in support, when President Obama took the stage with the sweet lady from Ohio with cancer who couldn’t get health insurance.Continue reading…

Health 2.0 @ SXSW

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By Matthew Holt

My wonderful colleague (and Health 2.0’s Co-Chairman & CEO) Indu Subaiya has literally just come off stage in Austin, Texas where the annual South by SouthWest Conference has for the first time had a health track. Indu moderated a panel that included Aman Bhandari from HHS, Gilles Frydman from ACOR, Roni Zeiger from Google & Jamie Heywood from PatientsLikeMe. Judging by the Tweetstream and by this review on OpenSource.com from RedHat’s Ruth Suehle, the panel was a total smash. That’s not of course a total accident! Every one of those panelists and many others (like Jane Sarasohn-Kahn who’s panel is also today) are regulars at Health 2.0, and in some way Indu was taking SXSW a taste of the best of the Health 2.0 Conference. But the fact that the techie crowd at SXSW were lining up to get in is great news.

We desperately need more innovators to come into health care. We’ve been working with the whole Health 2.0 community to do that. Last year we introduced the Health 2.0 Developer Challenge, and this year we’re expanding it. Now other mainstream technology gatherings like SXSW and OSCON are helping spread the word. It’s heartening to read about people who are just discovering the amazing work of PatientsLikeMe, and in some ways it’s amazing that more people don’t know about this sector. But the time really has come to put America’s technology entrepreneurship to work in the heart of health care, and move it in from the edges.

And of course if you want to be ahead of the curve you should be at the Health 2.0 Spring Fling in San Diego in 8 days time!

Meanwhile, here are the latest news bites from our sister blog Health 2.0 News, including Teladoc & Aetna, Vitals buying Healthleap and more.

Why Berwick Matters

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By ROBERT WACHTER

Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline?

Both the yes and no arguments are made persuasively, and I found myself on the fence after reading them, perhaps leaning ever-so-slightly toward the “no” side (optimist that I am). Sure, times are tough, but we’ve got the Right Stuff and we’ve bounced up from the mat before.

Then I considered the political fracas over Don Berwick’s appointment as director of the Centers for Medicare & Medicaid Services (CMS), and decided to change my vote, sadly. Yes, America is in decline, and this pitiful circus is Exhibit A.

Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.

President Obama’s selection of Berwick to lead CMS last year was inspired. In the face of unassailable evidence of spotty quality and safety, unjustifiable variations in care, and impending insolvency, Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency. There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.

But Berwick’s nomination ran into the buzz saw of Red and Blue politics, with Republicans holding his nomination hostage to their larger concerns about the Affordable Care Act. In the ludicrous debate that ultimately culminated in Obama’s recess appointment of Berwick, the central argument against his nomination was that he had once – gasp – praised the UK’s National Health Service. Interestingly, without mentioning Berwick by name, Fareed Zakaria pointed to this very issue to bolster his “decline” argument in Time:

A crucial aspect of beginning to turn things around would be for the U.S. to make an honest accounting of where it stands and what it can learn from other countries. [But] any politician who dares suggest that the U.S. can learn from – let alone copy – other countries is likely to be denounced instantly. If someone points out that Europe gets better health care at half the cost, that’s dangerously socialist thinking.Continue reading…

Tough Talk

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By PAUL LEVY

Some people at the University of Washington and colleagues from around the country run a wonderful website called Tough Talk: Helping Doctors Approach Difficult Conversations. They call it a “toolbox for medical educators” who want to teach about ethics and communication. Topics include:

Common teaching challenges plus tips for recovering from them • Optimizing small group dynamics • Providing effective, honest feedback • Helping clinicians develop and operationalize personal learning goals • Motivating engagement and self-assessment in reluctant participants

Look at this statement of philosophy:

Many argue that ethics and communication cannot be taught. Since these skills lie in the realm of the interpersonal, they do build on skills and practices we begin developing from our earliest interactions. However, evidence shows that practice and experience can lead to development and enhancement of these skills. This human element is where the moral work of medicine happens. We have a responsibility to attend to these skills and work to develop them, even as we strive to perfect our other core clinical skills. Quality patient care depends on it.Continue reading…

Quality or value? A Measure for the 21st Century

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By MARYA ZILBERBERG, MD

One of the founders of the evidence-based medicine movement, Muir Gray

Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?

Well, let’s define the terms. The Merriam-Webster dictionary defines quality as “the degree of excellence.” The same source tells us that value is “a fair return or equivalent in goods, services or money for something exchanged.” To me “value” is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?

Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let’s take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.

But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions — they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?Continue reading…

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