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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…

Why Medical Ethics Should Matter to Patients

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By MICHAEL KIRSCH, MD

Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.

We physicians face ethical dilemmas every day. They won’t appear in your newspapers or pop up on your smart phones, but they are real and they are important. Here is a sampling from the everyday ethical choices that your doctor faces.

How would you act under the following scenarios?

1. A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?

2. Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred?

3. A patient has been non-compliant with medical care. He has missed appointments and does not take his medication reliably. The physician is contacted by a local emergency room after the patient arrives there for a medical evaluation. Can the doctor ethically decline to treat this patient who has repeatedly rejected the physician’s advice?Continue reading…

Nurses: Protocol -ed to Extinction?

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By SARAH BETH COWHERD

If you have been at your nursing job for a while, you’ve probably almost forgotten.

Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.

At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.

Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I LOVE what I do. I am so thankful for the opportunities set before me.

But whatever happened to “nursing judgment”? Or “nursing decision”?

I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”

I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”

Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.

Even so, to me it seems we are being protocoled to extinction.

Continue reading…

Why Apple iPad will Dominate in the Enterprise

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By JOHN MOORE

Ok, before I even begin, let me put it right out there: I’ve been using Apple products since I first got my hands on one of those cute little Mac SEs in the late 80′s having given up my spanking, brand new Compaq 386 with 64kb of RAM and a dual 3.5 & 5.25 floppy drives to a post doc at MIT who traded me the Compaq, which he needed to finish his thesis, for his Mac. I never looked back. I will attempt to keep that bias in check in this post.

Tomorrow, Apple will formally release the iPad 2, a device that has seen extremely strong adoption in the healthcare sector and even one of the HIT industry’s leading spoke persons, John Halamka of Boston’s Beth Israel Deaconess Hospital (he’s also Harvard Med School’s CIO) spoke to the applicability of the iPad in the healthcare enterprise in the formal iPad 2 announcement last week.

The iPad 2 release is happening while most other touch tablet vendors including HP, RIM, Cisco and those building Android-based devices struggle to get their Gen 1 versions into the market. Of these other vendors, only Android-based devices are available today, including among others the Samsung Galaxy and the Motorola Xoom.

But it is not so much the new features in the iPad 2 (e.g., lighter weight, faster processor, two cameras, etc.) that will continue to make the iPad the go to device for physicians and healthcare enterprises, it is the process by which Apple vets and approves Apps that are available in the App Store. Apple imposes what at times for many App developers is an arduous and at times capricious approach to approving Apps. This approval process is in stark contrast of the one for Android, which is based on an open, free market model letting the market decide as to which Apps will succeed and which will not.Continue reading…

Government Failure

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By JOHN GOODMAN

I can’t even count the number of articles and blog posts I’ve seen asserting that markets can’t work in health care.  Or that they work very imperfectly.  Or that they suffer from serious “market failure.”  In every case, the writer just assumes that government can remedy these problems.

Yet when Gerry Musgrave and I wrote Patient Power, we concluded that our most serious health care problems stem from bad government policies, rather than from markets failing to work.  In other words, “government failure” not “market failure” is the source of most of what is going wrong.

Why is our perspective so different from so many other health policy analysts?  I think the answer is:  the vast majority of people in health policy do not understand the concept of “government failure.” For example, health economist Austen Frakt, following Nobel Laureate Joe Stiglitz produced a list of “market failures” in health care and in health insurance at his blog recently. These include imperfect competition, unequal access to information, external costs and benefits for others generated by private activities, etc. He then offered this observation:

In principle, government intervention can increase that benefit (economic welfare) in such cases.  In practice and in some cases, it’s debatable.

How does Austin know that government “in principle” can solve these problems without a model of government decision making?  He can’t.  Moreover, it turns out that many of the factors alleged to cause “market failure” also contribute to “government failure.” In fact, in the political sphere their impact is much worse. Here is the bottom line: There is no model of government decision making in health care (and in most other areas as well) that shows that government will reliably improve upon the market. (At least a real market.)Continue reading…

Observations About the Israeli Health Care System

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By PAUL LEVY

As I share this view from my room in Tel Aviv after leaving the conference in Haifa, it is a good chance to consider the features of the Israeli health care system and draw some comparisons with that of the US. You can find a full description here, but let me hit the highlights as I understand them, based on discussions over the last two days.

Israel has had universal coverage for many years. It is provided by four HMOs, one with about 55% of the market, another with 20% or so, and the remaining two splitting the rest. The competition that exists is not based on price. Indeed, the cost of care is covered by a payroll tax and other government funding in the form of a capitated payment to each HMO based on enrollment. People are free to shift from one HMO to another as often as every two months, but only a very small percentage (well under 2%) shift each year.

Supplemental insurance, privately paid, is also available. However, the basic coverage offered to the population is very inclusive, and the supplement is for the small number of elective items that are not of great interest to most people.

The HMOs offer a strong primary care network and then contract with the hospitals for secondary and tertiary care. Some hospitals are owned by the HMOs, but many of the patients go to hospitals that are not owned by the HMOs. These are either government owned or are private, non-profits.

Now, as we explore transactions among these entities, it gets interesting. What is the process by which the rates for the government hospital are set with the HMOs, for the services purchased by the HMO out of its capitated budget? This is a negotiation in which the government is a participant. But recall that the government also owns those hospitals for which it is negotiating the rates with the HMOs. The HMOs are not permitted to joint together to negotiate with the government.Continue reading…

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