Matthew Holt’s EOY 2017 letter (charities/issues/gossip)

Right at the end of every year I write a letter summarizing my issues and charities. And as I own the joint here, I post it on THCB! Please take a look–Matthew Holt

Well 2017 has been quite a year, and last year 2016 I failed to get my end-of-year letter out at all. This I would like to think was due to extreme business but it probably came down to me being totally lazy. On the other hand like many of you I may have just been depressed about the election–2016 was summed up by our cat vomiting on our bed at 11.55 on New Years Eve.

Having said that even though most of you will never comment on this letter and I mostly write it to myself, I have had a few people ask me whether it is coming out this year–so here it goes.

2017 was a big year especially for my business Health 2.0. After 10 years my partner Indu Subaiya and I sold it to HIMSS–the biggest Health IT trade association and conference. And although I used to make fun of HIMSS for being a little bit staid and mainstream, when it came to finding the right partner to take over Health 2.0’s mantel for driving innovation in health technology, they were the ones who stepped up most seriously. From now on the Health 2.0 conferences are part of the HIMSS organization, and Indu is now an Executive Vice President at HIMSS. I’ll still be very involved as chair of the conferences and going to all of them but will (hooray!) be doing a lot less back office & operational work. (Those of you in the weeds might want to know that we are keeping the Health 2.0 Catalyst division for now at least)

That does mean that next year I will have a bit more time to do some new things. I haven’t quite figured out what they are yet but they will include a reboot of (my role at least) on The Health Care Blog and possibly finally getting that book out of the archives into print. But if you have any ideas for me (and I do mean constructive ideas, not just the usual insults!) then please get in touch. You can of course follow me on Twitter (@boltyboy) to see what I’m thinking with only modest filtering!

On the home front we are now firmly established in San Anselmo, which is a nice little suburban town about 40 minutes north of San Francisco. I have been trying to ride my bike into the city via the ferry a few days a week but unfortunately I’ve had two stolen in SF this year, so I’m ending the year being a couch potato. We do have big plans for the winter, and from early January will have a place in Tahoe City. If you and yours are looking go skiing, we probably have a bed for you, so get in touch.

Amanda continues to amaze me in that she manages to get Coco (6) and Aero (3) organized and active, into their respective first grade and preschool classes, all the while doing great things to the house. She’s also taking part in a really serious exercise class called the Daley Method more or less every day (I make it to yoga about once a month on average!). She tells me it’s essentially a religious cult and I’m waiting to see when she will bring home the orange juice for me to drink. Meanwhile she is in fantastic shape and making me look feel extremely flabby. Okay, so that’s enough about me and the family. There tends to be lots more with pictures on my Facebook page

For those of you who don’t know I started writing this letter way back in 2000 when I didn’t have a wife or family and presumably had a lot of spare time on my hands–not that I can remember exactly what I did with it. The main point of this letter is to tell you about the issues that I think are important and and which charities I support. In fact back in 2000 I used to find that my friends and acquaintances was so ill-informed about the world and politics that I was on a little bit of a crusade to tell them more. The good news is that in 2017, everybody seems to know everything, and everyone has an opinion. And yes it’s not too hard to figure out what mine is. The bad news is that many of us seem to have arrived in that state of greater awareness by living in countries that have either elected the worst populist buffoon of all time as president, or seem to be voluntarily committing economic suicide. And yes I am referring to the country I moved to and the country I moved from in 1989.

My views will become apparent in the way I divide this letter up. Please feel free to poke around and look at the links, and  maybe even donate to one or two. Let me know any comments or insults!

Health care & (poor) women’s & kids care & safety, and supporting patient activism

In the US this past summer there was a very serious attempt to destroy the Affordable Care Act. It failed–only just–but the rug is being pulled from under it by a bunch of mean spirited administrators put in charge over at HHS by the asses in the White House. Not to mention that the Congress (and we know who is in charge) has NOT RENEWED funding for the health insurance plan passed in the 90s for poor kids called CHIP. If you want to stay informed on all this I urge you to follow ex-CMS administrator @ASlavitt & blogger @charles_gaba on Twitter. @charles_gaba in particular is a one man band doing remarkable work classifying the actual on the ground impact of all of this on everyday Americans, and he gets no support for it. So you might join me and toss him a few bucks. The US health care system is still extremely screwed up, and if you want to know more you could do a lot worse than reading former NYT reporter Elizabeth Rosenthal’s An American Sickness. Other than hoping we get a Democratic sweep in 2018 & 2020 (and working and contributing $$ for that) I’m not sure what we can do to improve the system–other than to keep exposing the idiocy of current policies and the bad behavior of many actors.

For my next health care issue I’m just going to repeat what I wrote in 2016 and multiply it by a hell of a lot —What sadly has come into focus this year is the desperate attempts to attack women’s access to health care. If you’re a woman– especially a young or poor one who needs access to contraceptives, mammograms, cervical cancer screening, sexually transmitted disease testing, and all kinds of health procedures including safe abortions, it’s become the mission of mainstream Republicans to stop you getting them–using disgusting, deceitful, and downright illegal methods. And that’s as polite as I can say it. So my biggest bump in funding this year went to the one organization that consistently not only campaigns for but actually provides reproductive health services (including contraception, STD testing, counseling, pregnancy support and, yes, safe abortions), Planned Parenthood. I cannot believe that men want to live in a world where women cannot get these services, although I guess the evidence shows enough do….especially in Texas, Louisiana, Indiana and many more.

Given the #MeToo movement we can no longer ignore sexual assault as both a health and a social issue. A brilliant young entrepreneur called Jessica Ladd runs a non-profit called Callisto which enables victims of assault to report it without going through the harrowing ordeal of reporting it to the police or college authorities. Of course if several people report the same perpetrator then that helps bring them to justice. Now imagine this more widely used, say in Hollywood about Harvey Weinstein. Something like that is Jess’ aim. You can see her on Seth Myers’ show and also donate here.

Also worth noting is another great female CEO (Emily May’s story is here) who founded a non profit called Hollaback which helps report and prevent street harassment. There’s an app you can download to report harassment and of course they could use a donation too.

Finally in this section are two related entities supporting patients in dealing with the health care system. I’m a corporate supporter and personal member of the Society for Participatory Medicine which is moving from being a small core of activists to a major organization creating partnerships between patients and the health care system. They had their first conference back in October and it was excellent. The other is The Waking Gallery of which I’m also a proud member. Artist and activist Regina Holliday literally paints patients’ stories on the back of jackets and over 400 people (including me) now wear them at health care conferences. You can support her work here.

Other long time health care issues I like to think about/support:

• Engage with Grace founded by my friend Alex Drane. No donation needed–use the 5 questions you can download to start that hardest of conversations about what you want for your care at the end of life.
• Jeremy Nobel’s Foundation for Arts & Healing is engaging patients in arts, aggressively tackling loneliness support here.
• YTH, a really cool organization that helps use technology to educate young people about sex and other health issues. The YTH Live conference is in San Francisco in May & it’s great and cheap (and somehow despite desperate efforts to quit I’m still on the board).

Poverty in developing countries

The good news is that in the long run things are getting better. The bad news is that there are plenty of trouble spots from Myanmar to Syria to Africa and lots of forces and people trying to repress the long arc towards equality, peace and freedom.

I’ve supported Mercy Corps for over a decade now–at least that’s according to the card they just sent me. They do a remarkable job all over the world focusing on educating girls, supplying clean water and directly intervening in crises. It’s worth noting that this year those crisis spots included Puerto Rico because of the appalling ongoing incompetence of the US government in failing to get help to that stricken part of its own country!

Heifer International gives animals directly to the very poor in order to get them out of the cycle of poverty. Every year I hand out goats and chickens! Hey, my father has a farm on which he feeds the chickens and that’s about as close as I get any more. (OK, this year it was a pig)

I’ve always supported a few smaller charities. They are all teeny in the grand scheme but a lot of little things add up, and for each one of these any donation or support means a lot.

Saigon Children’s Charity is a small charity (approx $1m a year in donations) focusing on providing rice, bikes and books and pens to the families of very poor children in Southern Vietnam so they stay in school. I support a few individual pupils.

Sadly the rapids where I went rafting on my honeymoon in 2008 at the source of the Nile in Uganda are gone, but kayaking doctor Jesse Stone’s clinic and charity Softpower Health is still there. It sells cheap mosquito nets, and provides a health center and family planning outreach. Here’s an article about their first ten years and a really great case study from Jesse about how they saved a girl’s leg.

Also supporting direct medical care, We Care Solar makes a suitcase-sized portable solar powered generator and supplies it to health workers in off-grid clinics across the world–one frequent user is my friend Dr Enoch Choi who’s on the scene of basically every disaster. and right now is on his way to Cambodia. You could alternatively give to Power the World which provides Nokero solar lights, the WE CARE Solar Suitcase, SOCCKET (all of which I’ve featured in previous years) and clean cook stoves–of which I bought a few for people in Nepal.

In the same vein, Health eVillages is a charity launched at Health 2.0 by Donato Tramuto which delivers iPads & smartphones with preloaded medical information to clinicians in remote parts of Haiti, Kenya, South Sudan and elsewhere.

One of the worst trouble spots in the world is the genocide going on in Myanmar. 600,000 Rohingya people have been systematically driven from their homes–with thousands raped and killed by the Myanmar military. A small Muslim lead charity (very highly rated by Charity Navigator) called the Zakat Foundation of America is in the camps in Bangladesh working with the refugees–they are also working in Syria.. For the price of a bottle of good champagne I feel my donation made a bit of a difference and you might too.

Poverty in the US

Income inequality in the US is increasing, leading to systematic pressures on those at the bottom end of society’s ladder. This year the UN actually sent an investigator to report on extreme poverty in the US. The Guardian article about it was harrowing.

These organizations try to help in my locale. You of course may have your local favorites–Here’s the list I support:

• San Francisco & Marin food bank. Put your zip code in here to find out your local equivalent
• Hamilton Family Center, is a small shelter offering emergency and transitional care, as well as getting families into permanent housing. If you live in San Francisco you know that the housing situation is dire at any income level and is getting worse. Think about those at the bottom. You can help by clicking this link.
• Homeless Children’s Network supports care services for homeless children. No one should have to start life that way. You can help here

Disasters

This year has of course been terrible for disasters in the US–hurricanes in Puerto Rico and Texas and fires in California. I gave to the Hispanic Foundation for Puerto Rico, the greater Houston Community Relief Fund, the Redwood Credit Union Community Fund (for N. Cal fires) & the United Way of Ventura County fund for S. California. (Yeah, I know it has a bad rap but the United Way pledged that 100% of the funds will go to victims).  

I also met a bright young social entrepreneur called Jason Friesen from TrekMedics which is building a 911 system where there are none. I was thrilled that we could feature him at Health 2.0 this year. You can donate to their work in Puerto Rico here.

Torture and human rights

Imprisonment without fair trials and torture doesn’t work to improve safety and it increases the amount of future terrorism. My own grandfather was tortured as a British POW in WW2 in the far east. And yet we now have “strong” men in charge increasing the use of torture, unwarranted imprisonment, and in some cases selected or mass vigilante executions in Russia, Turkey, Hungary, Poland, the Philippines, and (if he gets his way) in the US.

These organizations help those being tortured (or who have been) and protest those governments who should act better.–which basically means all of them

• Amnesty International campaigns on behalf of prisoners of conscience everywhere
• The UK-based Freedom from Torture (used to be called Medical Foundation for the Care of Victims of Torture) helps people from many countries who have been tortured. I’ve been supporting it for many years
• The American Civil Liberties Union. If you’re not a card carrying member, you should be–this year of all years.

The environment.

While the clock ticks, the planet and the sea warms and we can but hope that technology in the form of renewable energy and replacements for animals being used as food get here in time. Our grandchildren will be ashamed of us. And of course we now have an actively anti-science administration in the US that is making the problem much worse. While I’ve been the biggest meat eater I know for many years, I’m cutting way down on beef which is responsible for 50%+ of global warming from agriculture worldwide & hoping that Impossible Foods and Memphis Meats come good on their promise to replace meat entirely. BTW the Impossible Burger is pretty damn good.

Other bad news is that the Japanese continue illegal whaling to a great extent and have essentially seen off the attempts by Sea Shepherd to stop them.

I give to both the Sierra Club (respectable) and Greenpeace (more radical) and locally to the Marine Mammal Center–a wonderful facility that helps seals recover, including most years one or two that get shot!

Drug prohibition—a terrible idea that is closer to being toppled

I’ve been protesting drug prohibition forever. It’s a terrible policy. You only have to witness Portugal’s experience decriminalizing all drugs and supporting those who want to get away from addiction to realize that there are much better policies actually working in real life. Probably lunatic US attorney general Jeff Sessions will be too busy trying (and hopefully failing) to avoid jail on perjury charges to try to block legalization of marijuana in California (and Washington, Oregon & Colorado). But we certainly don’t have anything like a rational approach coming from the Federal government even though the argument is basically won in the court of public opinion and science.  A system of taxed and regulated drug distribution is the only solution to removing the criminality associated with drug taking, much of which is relatively harmless anyway. I support:

• DRCNet home of the best blog and email newsletter, the Drug War Chronicle. They also look at the stuff others miss, like the massacres currently going on in the Philippines. Their review of the last 20 years of the drug war is well worth reading.
• The Drug Policy Alliance — the main lobbying organization promoting “harm reduction”

A Dog’s Life

Charley is 14 now and finally gets to hang out in a big back yard and doesn’t go into the office any more. Funnily enough as soon as he left, Health 2.0’s landlord rewrote the building’s rental agreement to make it a lot less dog friendly. Coincidence? Maybe not! For dogs that aren’t as lucky, Amanda and I support Rocket Dog Rescue $50 pays for an adoption.

***

OK, that’s it. Thanks for reading and please feel free to email me or tweet me or FB me or whatever to give your comments, or see if there’s some other charity I should support. Or just to get in touch anyway

Cheers & have a great 2018!

Matthew

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The Health Care System in 2018: Combat Zones to Watch

By PAUL KECKLEY

Entering the home stretch on 2017, the stage is set for some classic duels next year: they’re about money and control and they’re playing out already across the industry. Here’s the five combat zones to watch:

Hospitals vs. insurers: This is the quintessential struggle between two conflicting roles in our system. Hospitals see themselves as the protector for a community’s delivery system, bearing risks for clinical programs, technologies and facilities that require capital to remain competitive. Insurers see themselves as the referee for health costs, calling balls and strikes on the necessity and cost-effectiveness of improvements providers deem essential. Each sees the other as complicit in healthcare waste and guard jealously their leverage: hospitals enjoy community support and physician relationships and insurers controls premiums. Around the country, the combat zones involve stand-offs involving reimbursement negotiations and narrow networks (i.e. Mission Health (Asheville NC) and Blue Cross of NC), coverage determinations by insurers that impair hospitals (i.e. Anthem’s decision to deny coverage for unnecessary emergency room use) and others.

Integrated Systems of Health vs. the Federal Government: The federal government’s scrutiny of the ATT-Time Warner combination is being touted as a case study in vertical integration. And before the end of the year, CVS’ takeover of Aetna is anticipated—horizontal integration. The sectarian borders in key sectors of healthcare are already blurred: more than 100 health systems now operate insurance plans and 33% of physicians are employed in hospitals, so the stage is set for challenges by regional systems of health to federal constraints on the scale and scope of services offered. Since 2014, hospital consolidation has resulted in more than 700 deals as hospitals seek to gain leverage in payer contracts and reduce their operating costs. The historic methodology used to protect competition among hospitals is based on a community model: CMS says there are 457 discreet hospital referral regions and regulators are keen to protect against too much consolidation among hospitals. But hospitals trade with sectors that are much more consolidated with operations spanning states and entire regions i.e. the five biggest private insurers control 44% of the insurance market, and the 36 Blue Cross plans control 106 million members through their statewide operations. The issue is scale and scope; the combat zone is the court system, where hospital consolidation (horizontal integration) will be challenged and where vertical integration will be closely watched. And beyond the scale advantages enjoyed by insurers, the potential role that mega-players like Amazon might play looms large as hospitals shift from their acute chassis to fully integrated, regional systems of health.

States vs. drug manufacturers, distributors and pharmacy benefits managers: Prompted in part by increased attention to the opioid epidemic that’s costing $95 billion annually and is responsible for 64,000 deaths last year and by double-digit price increases for branded drugs that hurt their Medicaid budgets, states are cracking down on drug manufacturers and distributors. Attorneys general in 41 states are parties to a suit brought last month to address the opioid epidemic and many are seeking to protect their states price gouging. At least 176 bills on pharmaceutical pricing and payment have been introduced this year in 36 states, according to the National Conference of State Legislatures. Maryland’s law (House Bill 631), which imposes fines for “unconscionable increases” which took effect October 1, is the most aggressive but there’s no doubt state and local governments have zeroed in on the industry. The combat zone will be state legislatures, where the pharma industry—including manufacturers, distributors and pharmacy benefits managers—will be scrutinized. The industry will counter that its medications save lives, its innovation key to the safety and quality of the American healthcare system, and its aggregate spend—about 10% of total U.S. health spending—is unchanged for a decade.  And they will spend millions on lobbying to thwart efforts by states that limit their ability to price their products as they deem necessary.

Nurses vs. hospitals: According to the Bureau of Labor Statistics’ Employment Projections 2014-2024, the Registered Nursing (RN) workforce is expected to grow from 2.7 million in 2014 to 3.2 million in 2024, an increase of 439,300 or 16%. The Bureau also projects the need for 649,100 replacement nurses as many retire or cutback bringing the total number of job openings for nurses to 1.09 million by 2024. Per the American Association of Colleges of Nursing, the demand for nursing will not be met by nurse education due to lack of faculty and stress associated with the job that’s driving many experienced nurses to retire.  Hospitals are the front line for the growing tension building with nurses: studies showing correlation between nurse staffing levels and patient outcomes are forcing hospital operators to test ways to do more with less.  Per Standard and Poor’s (August 24, 2017), margins in hospitals are eroding: labor costs, especially costs for nursing and mid-level skilled positions, play a key role. The Congressional Budget Office estimates up to 60% hospitals will have a negative operating margin by 2025, so financial pressures will continue to be a wedge issue separating hospitals and nurses. Not surprisingly, nurses are unhappy. Though 445 hospitals have achieved magnet status (8.8% of total) implementing evidence-based nursing care in their policies and procedures, the majority haven’t. The combat zone is local: in every community, nurses think hospitals are preferential in addressing the needs and wants of physicians while subordinating work-place healthiness for nursing. They believe quality of care is being compromised by inadequate nurse staffing and they’re speaking out.

Physicians vs. outside control: The nation’s 861,000 physicians in active practice represent a profession that’s the centerpiece of our entire healthcare system. It controls the supply of clinicians and defines the scope of practice allowed for its members other health professions using state licensing, credentialing, and medical education to control what every profession is allowed to do. It disciplines its own vis a vis credentialing and peer review processes. It commands respect and trust: per Gallup’s occupational trust surveys, it ranks just behind nursing and on par with pharmacists. And financially, it’s rewarding: median income for physicians across all specialties ranges from 3.5 to 8 times the median household income of the U.S. population. But physicians aren’t happy. A 2016 survey of 17,000 physicians conducted by Merritt Hawkins on behalf of The Physicians Foundation revealed that about half of all doctors were feeling burned out and fed up with the healthcare industry, largely due to administrative hassles involving paperwork, mandatory reporting and scrutiny by outside parties. Per the Physician Sunshine Act, information about physician Medicare billings is now widely accessible, and health researchers are keen to expose physician inattention to clinical best practices. So, discontent among physicians is increasing, including those employed in hospitals. As reimbursement shrinks, reporting requirements increase, and report cards about physician performance are more widely accessible, the combat zone will be organized medicine’s determination to be left alone.

Complicating each of these disputes is a regulatory environment for healthcare that’s constantly changing, an austere fiscal environment in states that fund half of Medicaid and oversee provider licensing and private insurance, investors and lenders that are becoming cautious and the noise surrounding Campaign 2018 wherein contrasting views about the future of the healthcare system will be prominent. Regrettably, these combats will not answer the bigger questions facing our industry: Is healthcare in the U.S. a fundamental right or personal choice? Is our healthcare system a federal program or better run by states? Do we need to ration care, and if so, how and so on? Combat zones, by definition, focus on short-term issue resolution but sometimes lead to all-out war where the need for fundamental change is recognized. That might be where we’re headed.

In our country, powerful forces are competing for control and power over our $3.2 trillion system. When a sector’s role is threatened or regulatory policies shift favor to one over another, battle lines are drawn and combat zones result. Next year, we’ll have at least five to watch.

Paul

P.S. Over the weekend, I found myself comparing lists of Top Hospitals: IBM Watson Health’s 50 Top Cardiovascular Hospitals (formerly Truven Health 50), 2018 released November 6, 2017 (Modern Healthcare) compared to US News and World Report 2017 Best Hospitals for Cardiology and Heart Surgery (which lists 48 organizations). Both use credible methodologies to rate hospitals involving quality and safety measures, yet only 3 names appear on both lists: Duke, Mayo and Mt. Sinai (NY). Go figure!

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What’s Wrong With American Doctors?

By BRIANNA GRAFF

It is February of 2005, and my grandpa is lying in an Intensive Care Unit bed at Beth Israel Deaconess Medical Center in Boston, critically ill from a renal artery rupture that planted him face-first in his parlor. As a functioning alcoholic who has already been in the hospital for a day, he is beginning to shake periodically, a sign of his withdrawals.

Still, it will take another twelve hours and exasperations from both my mother and grandmother (both nurses themselves) before the physicians get him the Ativan he needs to combat this symptom, which is small potatoes compared to his emergent reason for admission.

While he would eventually make a full recovery, in those few hours my grandpa had tremors he was also the unintended victim of “tunnel vision” exhibited by many physicians: they see the most prominent problem and address it, often losing grasp of a holistic view of the patient and neglecting his humanity in their attempt to treat him. In short, they see the medical problem as opposed to the entire person.

Of course, this doesn’t mean that doctors are heartless: the number one reason doctors choose the profession is to help people, and the grueling work it takes to become an MD is clear evidence of their devotion to their career. So how did we end up here, with doctors overlooking the humanistic nature of their work?

The answer: their education. The one system we trust to build our caretakers is also giving them the short end of the stick in the social aspect of their work. Physicians take a slew of scientific courses to prepare them, but few get valuable social education. Clinical experience doesn’t begin until the third year, whipping through short rotations and involving a “hidden curriculum” in which students learn to communicate with patients by watching their superiors. What results is a breadth of experience, but no depth in bedside manner.

According to a study published in the Social Problems journal, doctors feel they can learn more from the medical chart than from the actual patient. What’s more, their main motivation for speaking to a patient is to gather information for said chart. To top it off, doctors spend hours making rounds, discussing the patient publicly among colleagues but rarely addressing the patient directly.

One junior resident in the study summed it up perfectly: “If you don’t sit and talk with a patient for a half hour, in terms of your job description no one is going to be mad at you. But if you don’t know what the hemoglobin is on the patient, the chief of medicine is going to be very upset with you.”

Clearly, doctors are more concerned with getting the job done than having a personal touch with patients. This might be beneficial—the more people they can cure, the better, right? Not true. A study conducted at Stony Brook University shows that compassionate, attentive care results in better therapeutic impact for patients and lowered depression rates with elevated career meaning for physicians.  It creates a better reputation for a healthcare facility at no greater use of economic resources, too.

Appropriately educating our physicians to be socially competent might seem difficult to add to their quest for an encyclopedic level of scientific knowledge. However, some schools are already doing it. Harvard and NYU give medical students practice with patients from day one. Schools increase their diversity to give their students a wider perspective and more capacity for empathy. It is proven that we can teach people how to express compassion in the clinical setting, which alone could dramatically improve the way we provide care.

We should be implementing these strategies across the board, as opposed to hoping doctors inadvertently learn communication through fleeting clinical experiences.

In a world where quantity supersedes quality, we need to take back the reigns and create renaissance men of medicine, where the demands of education don’t erode the ethics of students and destroy their idealism for their careers. The welfare of patients, doctors and the entire healthcare system depend on it.

Brianna Graff is a nursing assistant in the Medical ICU at Brigham and Women’s Hospital and a pre-med student at Boston University.

 

 

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Why Consumers No Longer Want Fitness Trackers

Millions of Americans have adorned themselves with glimmering Fitbits, Jawbones, Nike Fuelbands, and Misfits, Basis, Withings, and Garmin bracelets over the years. The devices have become so mainstream even Grandma has one. Perhaps the fact that Grandma is now tracking her data means that the industry is ripe for a change.

Recently though we’ve seen the popularity of wearables wane considerably. This month Mike and Albert Lee, founders of myfitnesspal announced that they would be departing from Under Armour; and we learned that Adidas is dropping their wearables division entirely.

Why? Its a fairly easy question to answer. Under Armour spent 2017 falling from grace and it’s possible their waning interest in connected fitness is due both to financial constraints as well as a series of departures of senior-level talent including Robin Thurston (MapMyRun), and Mette Lykke (Endomondo). Looking at Adidas though, they are dropping their dedicated connected fitness division in favor of a more distributed and integrated approach.

With this shift upon us, what is next wave of innovation? Let’s look at two companies.

Habit, the bay-area based company, collects genetics, vitals and metabolism of their customers; and uses their data and machine learning algorithms to deliver personal nutrition plans that is align with the user’s health goals. Parsley Health is redefining primary care medicine by committing their doctors to whole-body health than to quick fixes and bonuses.

See live demos from Habit, Parsley Health, and more at Health 2.0’s WinterTech event on January 10thduring JP Morgan week.

Tickets are selling quickly so register today!

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Why An Individual Mandate Is Important and What States Can Do About It: Lessons from Massachusetts

By ROSEMARIE DAY

The sweeping tax reform package recently signed into law will eliminate the Affordable Care Act’s (ACA’s) individual mandate in 2019, which is projected to reduce the number of people covered by health insurance by 4 million in 2019 and 13 million in 2027, while increasing premiums in the nongroup market by about 10% annually.1 For taxpayers seeking protection from high health care costs, this is a potentially catastrophic result.
Say what you like about the individual mandate, it is clearly an essential component of the ACA’s “three-legged stool” that – along with guaranteed issue and premium subsidies – has been effective in expanding health insurance coverage to millions.

Why is an individual mandate important?

Several studies show that, in a market that requires insurers to cover individuals with pre-existing conditions, an individual mandate helps ensure a healthy risk pool, which in turn helps to manage cost, affordability and sustainability. We learned this in Massachusetts, in the early days of implementing our version of health reform (which later became the model for the ACA). We had something close to a “natural experiment,” in which we launched a subsidized healthcare program before we implemented the individual mandate (we put the carrots out before we brought in the stick, in other words). Researchers were then able to study what happened to the risk pool, before and after the mandate.

As illustrated below, when the Massachusetts individual mandate went fully into effect in late 2007, there was a much larger increase in the number of healthy enrollees compared with enrollees with a chronic illness.2 What’s remarkable is that nothing else had changed in the program – the subsidy amounts were the same, as were all of the other enrollment requirements. But once people in Massachusetts understood they had to purchase insurance, the number of healthy enrollees jumped up.

Based on these results, and other relevant studies, the following projections have been made regarding the impact of eliminating the individual mandate:

A 2015 RAND Research Brief3 found that the absence of the ACA’s mandate would lead to a 20% drop in individual market enrollment and a 27% drop in enrollment among young adults.

In January 2017, the CBO concluded that eliminating the individual mandate while retaining other market reforms such as guaranteed issue would “destabilize the nongroup market.”4

A potential option

So, in the absence of a federal requirement to purchase health insurance, what can states do to rebuild the stool? One potential pathway is to establish an individual mandate at the state level, as we have in Massachusetts. As part of the Commonwealth’s landmark 2006 health reform law, most taxpayers are required to have health insurance coverage that meets certain standards (known as Minimum Creditable Coverage or MCC). By law, tax penalties are set at half the premium of the lowest cost plan available to the individual through the state exchange – the Health Connector.

To manage this humanely, Massachusetts established an income-based affordability schedule was established which exempts those individuals for whom health insurance coverage costs exceed a certain threshold. (For example, in 2017 affordability was set at 0% of income for individuals earning up to 150% Federal Poverty Level and 8.16% at 400 FPL and over.) Exemptions may also be requested through the Health Connector based on financial hardship or sincerely held religious beliefs.

Key takeaways for states

States interested in pursuing an individual mandate should embrace the “three-legged stool” approach (including guaranteed issue, an individual mandate, and premium subsidies), because it is critical to ensuring a healthy risk pool and keeping more people insured. Fortunately, two of these three legs are still provided by the ACA, so states only need to address the second leg: the individual mandate. While the politics of requiring health insurance coverage may be difficult to navigate, the potential benefits of doing so are significant: a healthier risk pool which in turn helps manage cost; a higher number of people with health insurance coverage; and the ability for a state to have more control over its insurance market. It’s also worth noting that there is a robust level of participation of insurers in the Massachusetts individual marketplace, and there has been since inception of the Health Connector.

Other considerations for states include:

Government agencies need to work together to define, implement and administer individual mandate requirements (in Massachusetts, the Health Connector has worked closely with the Department of Revenue)

Tax penalties should be set at a level that encourages enrollment but doesn’t overly burden taxpayers

Reasonable exemptions to the mandate should be considered, and can be managed through the state exchange

Flexible affordability standards are key to ensuring low income individuals aren’t financially burdened

Premium cost affordability is important, but keeping out-of-pocket expenses affordable at time of service is also important and can be positively impacted through minimum coverage standards.

The author gratefully acknowledges the contributions of Ross Weiler, Principal at Day Health Strategies, to this blog. Rosemarie Day can be found on Twitter: @Rosemarie_Day1

Rosemarie Day operates Day Health Strategies and is the Former COO of the Massachusetts Health Connector.

1 Congressional Budget Office, Repealing the Individual Health Insurance Mandate: An Updated Estimate, November 2017

2 New England Journal of Medicine; Amitabh Chandra, Ph.D., Jonathan Gruber, Ph.D., and Robin McKnight, Ph.D., The Importance of the Individual Mandate – Evidence from Massachusetts, January 27, 2011

3 RAND Research Brief; Eibner C, Saltzman, How Does the ACA Individual Mandate Affect Enrollment and Premiums in the Individual Insurance Market? 2015

4 Congressional Budget Office, How Repealing Portions of the Affordable Care Act Would Affect Health Insurance Coverage and Premiums, January 2017

 

 

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An Ode to Evidence-Based Health Policy

By ANISH KOKA, MD

A recent kerfuffle ensued when a CDC analyst leaked details of a meeting that noted a list of banned words and phrases that included ‘evidence-based’ and ‘science-based’.  This most recent assault on reason from the Trump administration was lapped up by partisans as yet another example of the dangers of having reality stars occupy the White House.

Unfortunately no one apparently told the director of the CDC, who took to twitter to respond:

I want to assure you there are no banned words at CDC. We will continue to talk about all our important public health programs.

— Dr Brenda Fitzgerald (@CDCDirector) December 17, 2017

https://platform.twitter.com/widgets.js

Details are sparse.  A meeting took place.  Words were discussed.  No Trump administration official has come forward to take ownership of the meeting.

Regardless, we should all be relieved that we can now get back to the business of implementing evidence based health care policy.

How has that been going anyway?

Ten years ago this month Atul Gawande wrote a widely read article in the New Yorker called The Checklist.  In it he related a masterful riveting story of a 3 year old girl in Austria who slipped into an icy pond, and was underwater for 30 minutes.  On arrival to the intensive care unit, she required massive support – a heart lung machine, treatment and monitoring of brain swelling.  The end result in this case was nothing short of miraculous.  Two years later, she was like any other than 5 year old.  The point Gawande goes on to make is that the complexity of patients in the critical care setting is overwhelming.  In these sickest of sick patients even one mistake could be the difference between life and death.  Humans can’t do it – and the error rate that inevitably results is not one that society should bear.

The solution was the checklist.  Derived from the airline industry to avoid errors, porting this innovation that allowed the flying of planes safely to medicine, would make medicine more manageable and therefore safer.  Peter Pronovost, an intensivist at Johns Hopkins, started making use of a checklist when placing central lines to lower rates of infections related to the presence of these lines.  Remarkable drops in the rates of infections were noted and the era of checklist mania was upon us.  Dr. Gawande was sold, and as a young doctor, just finishing my training, I had no real reason to argue with him.  But as the years passed and I flailed about, losing hair and sleep at the bedside of the sickest of sick patients in intensive care units, the whole  concept started to seem absurd.  Yes, patients were immensely complicated.  Yes some patients died.  But as I went over what we could have done differently – I began to realize that prognosis in most of these patient had little to do with the actions of the team in the ICU.  The patient with a ruptured aneurysm in their brain related to an infection on a heart valve died for reasons that had nothing to do with better processes.  One patient’s infection was controlled by antibiotics, and the strands of bacteria flipping around with every heart beat stayed put or regressed.  The other patient treated in the same manner showered emboli, developed multiorgan failure as a result, and died.  The initial presenting condition was paramount to prognosis.  Beyond that, stochastic events – not expertise – seemed to guide patient outcome.  This doesn’t mean no errors ever took place, but that it was a rare event that could directly link an error to a bad outcome.

So ten years later it comes as little surprise that checklists have failed in a variety of arenas.  Just last week, the closely watched Gawande-inspired Better Birth Project to use checklists to improve maternal and fetal mortality in India was found to improve adherence to best practices, but was found to have no affect on mortality.  Apparently checklists weren’t enough to wipe out the disadvantages inherent in communities that subsist on $2/day.

Checklists didn’t even succeed in solving simpler problems that seemed ideal for the process like the “wrong site, wrong procedure, wrong patient” medical error.  There are few medical errors worse than surgery on the wrong breast, or even worse the wrong breast of the wrong person.  But it happens. Making this a never event became a mission for all sorts of agencies and checklists proliferated in hospital surgical staging areas.  As a boy growing up in India I had been accustomed to hearing the daily muslim call to prayer ringing out from the local mosque.  Who knew that as an adult walking through the hospital I would get used to hearing the health system prayer as nurses dutifully put doctors in ‘time-out’ to call out items from checklists. (This was especially loud when the Joint Commission visited).

If I had only chosen to dig a little deeper than a New Yorker article I would have found that this whole endeavor was doomed from the start.   As newsworthy as these events were, they were already almost never events.  The seminal study on the topic found a rate of errors of 1 in 112,000 procedures.  That means any one hospital would experience this event once every 10-15 years.  That’s a rate of disastrous complications the aviation industry would be envious of.  None-the-less, the pursuit of perfection in this arena brought us the universal protocol and its checklist from the aviation industry.  And it may have made things worse.

Really.

According to the Joint Commission, the era of checklists and Universal Protocols resulted in a higher rate of never events.

To be fair, I don’t know this for sure.  Perhaps the reporting improved, and the rate have been the same the whole time.  No one really knows.  But I think it would be reasonable to conclude that checklists didn’t result in these rare errors becoming never events.

The scale of the health policy evidence based blunders only get larger from here.

Remember The Cost Conundrum?  Also written by Dr. Gawande in the New Yorker, this was another powerful tale that built on data from the Dartmouth Eliot Fisher group that had mapped Medicare spending by county.  McAllen, Texas had the distinction of having the second highest per capita Medicare spending in the country.  A trip from Gawande to this little town uncovered a profit driven enterprise of doctors and hospitals milking the system.  The helpful solution was provided by a trip to the Mecca of healthcare in the United States that was low Medicare cost, but – the low cost, but high value Mayo Clinic.  A visit to a surgeon’s clinic there told of an hour long discussion with a patient followed by a cardiologist materializing within 15minutes from another floor to help ready a patient for surgery the next day.   How did they do this?

“..decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.”

The answer to the health care cost problem lay in this elegant article.  The plan as initially forwarded by Eliot Fisher from Dartmouth and now gracing the pages of the New Yorker was to create Accountable Care Organizations in the image of the Mayo Clinic.  Convert McAllen, Tx to Rochester, MN and the nations problems would be solved.

I never stopped to think, of course, exactly how Mayo was operating in this manner.  How could a surgeon at Mayo afford to spend a whole hour with a patient?  How exactly does a cardiologist have time to run down in the middle of the day to discuss a complicated patient?  If the cardiologist doesn’t bill the consultation, how is the cardiologist being paid?

These details were not provided, and these questions were never asked.  The Cost Conundrum was required reading for the framers of the ACA, and so health care was reimagined and jiggered to make winners out of large health care systems.  Cuts from CMS targeted private practice reimbursement.  Regulations that required reporting of practices through an electronic health record were applied.  The incentives quickly melted away to become penalties.  Private practitioners faced a choice : accept the lump of coal or join a hospital.  Most fled to hospitals, dotting the landscape with soup to nuts health care systems and realizing the dream Gawande had written about.

Except, Gawande and his adoring readers (that would include me) had been hoodwinked.  The secret sauce for this high value care being provided to patients by the very best in the field wasn’t in the Medicare data that Eliot Fisher’s group in Dartmouth had put out.  The drunk looking for keys under the lamp post doesn’t find his keys for a reason.  The keys in this case was where no one was looking – payments from private insurers.

Just down the road from where I grew up at Carnegie Mellon University came a paper based on claims data from private insurers that showed a much more complex Savannah than the Eliot Fisher data had lead anyone to believe.

The dollars paid by private companies was multiple of what was paid by medicare.  A knee MRI paid by private insurers was $1331, Medicare paid $353.  Even more startling was how Rochester, MN ranked relative to its peers in per capita cost.

While Rochester, MN was a bargain when it came to Medicare spending per beneficiary, it was one of the most expensive markets when it came to private spending per beneficiary.  The other large vertically integrated health systems (Grand Junction, CO – La Crosse, WI) that Gawande had highlighted? Also some of the most expensive on the private market.

Apparently, creating large integrated health system created a monopoly that could effectively name its price for the services it was rendering.  Medicare gets to set its prices – the private insurers have to negotiate with providers.  The fewer health systems in a county, the higher the prices negotiated.  THIS is what was paying for one hour patient visits with a surgeons and made Cardiologists materialize out of thin air.  The idea that any of these large health systems were low cost was a myth.

The New Yorker article was published June of 2009 and received widespread attention.  Barack Obama subsequently held a health care town hall Grand Junction, Colorado a few months later to highlight that members of the community were getting “better results and wasting less money” as part of the push to pass the Affordable Care Act.  The paper from Gaynor & colleagues arrived six years later in December 2015 to what would seem to be much less fanfare.  Gawande wrote a brief mea culpa,  acknowledging large health systems (like the one he had worked for his whole career) were not cheap, but they were still the path to providing high value care. It was just the cost side of the equation that had to be figured out.  The New York times did a wonderful bit of reporting (by Margot Sanger Katz) in their Upshot blog as well.  In today’s era were likes, clicks, and impressions declare victors, I would be willing to bet the non-narrative fitting paper and subsequent coverage lost by a mile.

I recall being profoundly disappointed on reading the Gawande mea culpa.  It was reflective of the approach of most of the policy folks in charge at the time.  Rationalization of one sort or the other were made – Coverage! Not Cost! – and the importance of staying on the path was reaffirmed.

This had been an exercise in a narrative in search of data.  It turns out that empiricism in health policy isn’t quite like the science of sending rockets to Mars.  Ideology rules – academics that worked for large health care systems produced data to support their world view.  Even the paper from Gaynor had been produced with the help of claims data from private insurers who formed the Health Care Cost Institute in 2011.  Everyone seemingly has a side of the story to tell.  The mistake may be to reimagine the healthcare system based on any one of these views.

Designing health care policy would seem to be a thankless task.  Some will no doubt conclude that we just need better data to design a more perfect system.  I am not so sure.  It may be that the lesson to learn from all this is to design as little as possible, and foster an environment that lets patients, not regulators, pick winners and losers in healthcare. The entrenched interests that control much of the flow of the $3 trillion dollars we spend annually are unlikely to let that happen.  They have lots of studies that say so.

Evidence based health care policy awaits, saved from the Great White known as Donald Trump.

I can’t wait.

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What Know and What We Think

ROBERT McNUTT, MD

What matters is what we know, not what we think

In the late 1980’s I cared for a pregnant woman with breast cancer. Breast cancer is the most common cancer in pregnancy, but uncommon in number, occurring in about 1 in 3000 pregnancies. It is a compounded emotional treating experience for sure, and at that time uncertainty in how to treat was the norm. The woman had a mastectomy but did not take chemotherapy based on concern for her baby.

Three months after her delivery, now getting chemotherapy for her aggressive breast cancer, the woman asked me to consider treating her newborn child with “mild” chemotherapy, a clear contrarian idea given her reluctance to expose her child while in her uterus. Her reasoning, she said, after giving it “lots” of thought, was that it made sense to her; she had cancer at a young age and reasoned her child would also. In her mind it was rational and reasonable to give her child treatment.

Fear and depression fueled her concern, for sure, and universally we would deny the request. The woman would not live to see her child’s second birthday and wanted to do what she could for her. But, there was no evidence of benefit to the baby, making her request irrational. So, I did not comply. In fact, what would you have thought of me if I had complied with this woman’s concerns?

In 1882 a surgeon reasoned that removing a woman’s cancerous breast, nodes, and muscles was the way to get rid of breast cancer. There was no proof of benefit, but the idea spurred action. That idea, and the radical surgery, persisted even after the publication of a randomized trial (NSAPB-04) in 1974 showing that more surgery was not better than less; yet, about 5000 radical mastectomies were still performed in 1983, about 100 years after the first. What should we think of physicians who acted without proof of benefit, and, even, after proof of no benefit?

In the 1990’s over 40,000 women had high-dose chemotherapy and bone marrow transplant if they had breast cancer. Some of those women died of treatment; I know so because I knew some. The intervening years between the ideas of doing more and more to a woman with breast cancer and the publication of randomized trials showing that more and more was actually less was marred by politics and legal threats for not performing the “best”, and most. All this wrangling occurred without knowing if the treatment plan was better than others. What should we think of those physicians, lawyers, and insurers who forced compliance and then complied with an idea rather than knowing what was best?

In a previous blog, I showed data on bilateral mastectomy for DCIS; there is data, but no information, as comparative studies have not been done [link]. I was consulted by several women who were considering complying with the bilateral procedure based on ideas that getting rid of everything might be good for them. Their physicians had proposed the procedure. What should we think of these physicians for proposing an unproven procedure based on an idea?

Acting without knowing, in my view, should be considered an abdication of professional responsibility. A professional obligation includes informing patients that there is no evidence of benefit for some treatment plans, and then not proposing the plan.

The only way a decision can/should occur is if there is a balance between compared options. The compared options must be examined in studies that give the best chance of determining the independent contribution of one intervention versus another (randomized). The balance that emanates from these studies is that some treatment will be shown to independently contribute to better disease related outcomes at the expense of more treatment related complications. The differences in outcomes of disease and treatment compete for a patient’s attention, and choice.

Without such comparisons, no choice should be made. Ideas don’t suffice; it doesn’t matter whether the ideas are the physician’s or the patient’s.

How many 100, 000’s of women underwent radical mastectomy before it took only 1700 in a randomized trial to show it offered no benefit despite increased harm? What about high dose chemotherapy and bone marrow transplant? Six randomized trials, reviewed in 2005, including only a cumulative total of 850 women, showed high-dose treatment offered nothing, but studies kept trying to prove the value until finally 14 randomized trials, now including 5600 women came to the same conclusion. Far more women got the procedures before knowing what was best than the number required to find out what is best in the first place. This should be a lesson to us all. Knowing is better than not knowing, and doing without knowing may be the worst thing a profession can do.

I am writing this blog with a purpose. That purpose is to make physicians and patients uncomfortable about acting on beliefs without evidence from comparative research trials. I believe patients are the best decision makers, but that will be shown to be true only if they are informed and allowed to decide.

But, physicians need to be on board, as well. They should not allow treatments of unproven benefit and, instead, they should demand study over action. There are too many examples of the failure of “good ideas” to subsequently help patients. What matters is what we know, not what we think. Informing patients that no evidence exists, and promoting a dutiful process of scientific inquiry could be a powerful way to change medical care for the better.

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Dr. Nuance versus Crusaders of the Lost Art

By, SAURABH JHA MD

 

The two writers who got inside my head were polar opposites. Christopher Hitchens was an atheist, who mocked religion incessantly, and spared few sacred cows – he went after both Mother Teresa and Bill Clinton, though for patently opposite reasons. G.K. Chesterton, the sardonic, plump Englishman, went after heretics. Hitchens destroyed orthodoxy. Chesterton mocked radicals. Hitchens once quipped that “what can be asserted without evidence can be dismissed without evidence.” Chesterton quipped that the rebel, the infinite skeptic, was in fact a decerebrate orthodox. If both were on Twitter they’d be trolling each other, non-stop. Though fighting on opposite sides, they had a commonality – they punished sloppy thinking, one with prose and the other with wit.

I’ve long wondered who would be healthcare’s Hitchens and Chesterton. Physician writers have generally been disappointments, because they veer, almost uncontrollably, towards tedious self-flagellation, ever keen to internalize medicine’s original sin – an imperfect science, a stubborn art. Unlike prophets of yore who risked harm in expressing their views, medicine’s prophets moralize from the comfort of their six-figure salaries. “We do too much”, they say, even as they’re grass fed by the excess they so disdain – count me in this army of hypocrites.

For many years healthcare watchers have been fed a steady stream of Disneyland economics, trite platitudes, which have simplified the complexities of healthcare – cheesecake factories and checklists, value not volume, “we must do things for patients, not to patients” (needless to say that often to do things for patients you must do things to patients), amongst others. Whatever purpose platitudes are supposed to serve, they bring all critical thinking to a jerky end. I recall several talks during the passage of the Affordable Care Act in which the speaker would romp to a standing ovation for stating blithely – “let’s pay doctors for doing the right thing”, with me still muttering “how?”

In the midst of getting carpet bombed by bromides I was forwarded a piece by Dr. Lisa Rosenbaum. I almost didn’t read the piece – I rarely read perspectives, other than mine. Before reading perspectives, I check their provenance. A young cardiologist writing in the NEJM – I was convinced this was another writer enthralled with Rawls distributive justice – another tedious medical moralizer. I was wrong.

In the piece Rosenbaum explored the complexities of defining quality and value, and difficulty in paying for performance. This was long before it became fashionable to question the value of measuring value. I could believe what was written, but I couldn’t believe that it was written, even less so that it was published. To mix a metaphor, it seemed that I wasn’t alone in the Potemkin village who saw that the emperor had no clothes.

Rosenbaum is neither Chesterton nor Hitchens, but in a space crowded with piety her writings are a breath of fresh air, and induce an uncommon, though not an unsurprising, amount of ire, such as her trilogy on physician-industry relationship. To make the case that money corrupts is easy and requires little courage, particularly in the age when disclosing financial conflict of interest is like brushing your teeth. To make the contrarian case that financial ties with industry lead to net benefits is dicey. But it is precisely because it is dicey that it extracts more linguistic muscle, more thought, more logic, and more courage. Rosenbaum delivered, and if her detractors prevailed, it was only by a whisker, and not for the lack of her prose.

Both Hitchens and Chesterton might have patted Rosenbaum for taking the unpopular side. Hitchens might have been happy that a sacred cow, such as our obsession with financial ties, went unspared, and Chesterton that the unfree radicals were gently mocked. I, for one, was just pleased watching the riot unfold on social media.

It is Rosenbaum’s most recent piece which has drawn the most ire, in which she asks whether the less-is-more movement has, in its missionary zeal, oversimplified overuse in its crusade against too much medicine. I should, at this conjecture, disclose that I’m a less-is-more apostle – I’d like to think that I’m more of a John the Baptist – I want others to run with it. Diagnostic and therapeutic, particularly diagnostic, incontinence offends me. I believe the role of medicine is to heal the sick, not hound the well.

One cause of angst was the use of “crusade” in the title of her piece. Bush Jr. realized that “crusade” isn’t a word which should be used lightly. “Crusade” relegates the less-is-more movement from science to religion, and is admittedly an unfortunate choice. But apt. Very apt. I invite you to watch this movie on the state of American healthcare, called “Escape Fire” – the analogy here is with a fireman who burnt a fire to stop a forest fire. The movie is sensational but tedious. I hoped Dirty Harry would walk in any moment and save me from soporification. I’m sorry – but if you believe healthcare reform is an “escape fire,” then you shouldn’t be offended by “crusade.”

Elsewhere, medical errors have been compared to a jumbo jet crashing every day, even to urban genocide. I struggle to understand how someone can remain inert by these hyperbolic, and frankly absurd, analogies yet be offended by Rosenbaum’s allusion to the holy war. What am I missing?

Rosenbaum’s strength is her weakness – her prose, which is so lucid that you know exactly what she’s saying, unlike that of many medical writers who use such barbaric prose that their thoughts remain stuck in their ampulla, means that the reader, drawn to arguing with the author, forgets that their intemperance is a testament to her skill. The job of a writer isn’t to tell you how to think but what to think about. Rosenbaum has achieved this marvelously.

A perspective isn’t a meta-analysis, it isn’t a quantitative truth, rather it is supposed to encourage the reader to examine the conventional wisdom, no matter how settled the truth appears. Thus, the charge that Rosenbaum’s piece should have been better peer reviewed misses the point – peer review is merely micro-group think. A good essayist shouldn’t just survive peer review but actively dodge it, if she wishes to challenge group think. A good essayist must take a stand, and Rosenbaum did, admirably.

For an essayist it is the post publication review which is important, and no better compliment to Rosenbaum could have been paid than by veteran journalist and a cardiology maven, who knows more about cardiology than cardiologists, Larry Husten, who tore into some of her arguments. Husten is a fine writer, too, and has an eye for controversy. It seems Rosenbaum got inside Husten’s head in the same way Hitchens once got inside my head – an applause to Rosenbaum for getting inside Husten’s head, and to Husten for graciously allowing her to get inside his head – it takes two to a dialectic. This is the way it should be.

I take one exception to Husten’s critique – in which he says Rosenbaum is an apologist for the status quo, a medical conservative. It is easy demonizing a healthcare system which has gained international disrepute – though oddly, doctors still queue outside the American embassies in New Delhi and Beirut. U.S. healthcare is so imminently disagreeable that pointing its flaws isn’t rocket science. What’s more challenging is understanding how we got here, what drives waste, and what will be forfeited if we curbed waste.

These inconvenient questions are repeatedly dodged by our thought leaders, but Rosenbaum refuses to ignore them – whether this is her strategy for conserving the status quo or changing it is beside the point – trade-offs exist. If Rosenbaum is supporting the status quo she is certainly not taking the path of least resistance. My guess is that Rosenbaum was exposed to Shakespeare very early on and literally read every single word in every single play, and has an uncommon, and rather unshakeable, appreciation of human complexity. Regardless, the point is that Rosenbaum didn’t invent trade-offs in healthcare – they exist despite her, not because of her.

Trade-offs mean you must choose. For some the choice between overuse and underuse is a false one. It is false if one considers underuse as a resource and access issue, and overuse as an abundance issue. It is unclear whether overuse creates an opportunity cost leading to underuse – the logical answer is that it does, and it certainly will in budget-constrained systems, though the effect in the U.S. is less clear, because overuse finances some of healthcare, it finances many services, including the less profitable ones.

Anyway, this is not the point I’m belaboring. Rather, I’m talking about trade-offs between more use (overuse) and less use in areas of abundance. How much is the trade-off? It depends. In some situations, such as incidentally detected thyroid nodule, the harms of overdiagnosis/ overtreatment overwhelm the miniscule gains so much so that trade-offs aren’t even worth exploring. In others, such as the new definition of hypertension and statins for primary prevention, there is a real trade-off between extending longevity in many, and conscripting many, many, more to the ranks of disease. I believe we’re overstretching – YMMV, and that’s fine, but we can at least agree on the trade-off.

Another example is imaging. In the diagnostic pursuit of potentially fatal conditions, particularly in low pre-test probability situations, such as pulmonary embolism, ischemic bowel, aortic dissection and acute coronary syndrome, there is a trade-off between false negatives – missed cases – and both the frequency of imaging, and the number of false positives. This trade-off is a fact of life, the basis of signal theory. Doctors overtest because of a culture of safety, a culture accentuated by reports from the Institute of Medicine that diagnostic errors are a plague, and defensive medicine, and societal expectations and not least because, as Rosenbaum candidly admits, “possibility is not the same as probability, but when you’re bearing the weight of another person’s life, the distinction often feels meaningless.”

Which is to say that physician decision making has become like Pascal’s wager – Pascal said that he’d rather believe in God than not, because if there was even the slightest possibility God existed, it was better to err towards believing in God, and thus enjoying heaven, than not believing in God. To borrow the language of option traders – there’s little downside to believing in God. For physicians, the possibility of a catastrophic miss looms large in their decision making. This is most evident in emergency medicine where physicians must decide whether their patient has a life-threatening condition based on imperfect information. Once you think Pascal’s wager – possibility and plausibility always trump probability, and the art of medicine, which is essentially probabilistic, is killed.

The emergency room, depending on your perspective, is either the swamp of waste or the epitome of appropriateness. Appropriateness is difficult to define, ex ante. Waste is a typical Tragedy of Commons – many physicians believes it is the other physician at fault. Emergency physicians blame cardiologists for clogging the outflow pipeline in to the hospital by doing too many stents for stable angina, cardiologists blame emergency physicians for over reacting to chest pain and weakly positive troponins, and radiologists – well we blame everyone but ourselves and our incontinent hedging.

To reduce waste, you must define appropriateness and what is appropriate depends on what you wish to achieve. Let me give you an example. In my days, when life was easier, we would literally ram a nasogastric tube down a patient’s throat, passed the squamocolumnar junction, until it reached the stomach – we were mostly, 98/100, times successful, but occasionally the tube would end up in the patient’s lung. This is now considered a “never event.” To prevent this “never event”, radiographs are taken as the tube is gingerly passed through the esophagus – multiple radiographs are taken until tube reaches the stomach. Is this waste? Depends if you think it is appropriate – regardless, the point is that you need lots of imaging to prevent a “never event”, to practice medicine like Pascal’s wager. Call this waste, call it whatever the hell you want – but there’s a trade-off.

I’ve heard a safety officer say – “we have too much waste and too many missed cases” – without conceding they’re part of the same problem. It’s like wanting a bath without getting wet. You can’t. The obvious retort is that it’s not about overuse or underuse, but an ephemeral “right care” – but that’s a cop out which pretends that trade-offs don’t exist, which isn’t true because as Rosenbaum diplomatically puts it, “it’s not clear that we have the evidence-based knowledge to reduce waste safely.”

I’d have gone a step further and said – let’s reduce waste, let’s make diagnosis more specific, less sensitive, let’s make clinical medicine an art again, and be forthright that it’ll come at the expense of missing a few catastrophic cases. Who is on board? Anyone?

It is quite likely that Rosenbaum and I aren’t equally perturbed by waste, I’m probably more perturbed than her. But we don’t need to agree precisely on how much waste is too much. All we need to agree on are the trade-offs. Because if we can agree on what the trade-offs are, we can at least agree on the terms and conditions of the fighting waste. I’ve seen very little in the less-is-more literature which explicitly acknowledges trade-offs, which concedes that the fight against overuse will come at a cost, but that cost is worth it. If we don’t acknowledge the trade-off we’re back to square one.

The ire against Rosenbaum is unusual. I’ve seldom seen anything like it. It’s as if people read her work and ask, “why aren’t you with us?” It reminds me of Bush Jr’s “you’re either with us or the terrorists.” Rosenbaum has been called “dumb” and “naïve.” Was Atul Gawande “dumb” for comparing healthcare to cheesecake factories, for selling checklists as our panacea? Were the creators of meaningful use “naïve”? Was the crew who brought you “in healthcare jumbo jets crash daily” dumb? If not, why such vitriol against one of the most courageous healthcare writers of our time, who has singularly brought back nuance in healthcare discussions?

Rosenbaum has not replied to a single Tweet belittling her. Brave lads – try this next time – try coming on Twitter several times a day, seeing your timeline flooded with sarcastic and condescending retorts from important people, and half-wits, and then bite your tongue and not retort. I don’t know how many lads will have the strength to restrain themselves – I certainly won’t.

I’m all for a colorful savanna. One of my favorite Tweeps is, in fact, a leading critic of Rosenbaum – Vinay Prasad, another courageous physician, with gruff, who can take on a movement, my natural ally in less-is-more. I’ve often wondered who is braver, Rosenbaum or Prasad. Then I realized that the question is moot. Because the healthcare savanna needs them both.

Meanwhile, can we please bring back the lost art of medicine?

Thank you.

 

About the Author:

Saurabh Jha is a radiologist and contributing editor to Healthcare Blog. He can be reached @RogueRad

 

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Losing Net Neutrality Could Be Bad For Your Health: Here’s Why

BY JOHN McDOUGALL, MD

The US Federal Communication Commission’s reversal of Obama-era net neutrality regulations sets the stage for broadband internet service providers (ISPs) to slow or block certain content from reaching their customer’s screens. This is likely to have a significant and potentially negative impact on a healthcare system poised to go fully virtual in the coming years.

Healthcare consumers already depend heavily on internet search results for advice when making healthcare purchases. Coupling preferred content with existing search engine optimization strategies will undoubtably steer consumer behavior. What will be the result? The American healthcare market is unique, both in its expense (higher than any other nation), and its shocking lack of value. Some of this is due to misinformed consumers swayed by direct-to-consumer marketing. Arguably, repealing net neutrality may amplify the problem.

Even more troubling is the prospect of an ISP partnering with a health delivery system. Telehealth – the use of electronic communication technology for healthcare delivery – will become standard of care in the coming years. National telehealth have already managed to get a foothold in today’s highly competitive healthcare market, supplying a disruptive and potentially cost-containing force in the healthcare market. With the elimination of net neutrality, larger, more well-established healthcare delivery systems, seeking to defend or expand their marketshare, can now partner with ISPs to preserve internet “fast lanes” for realtime video doctor’s visits. Smaller, possibly disruptive companies, unable to make these same financial commitment to ISPs, may be marginalized or lost.

Lastly is the idea that healthcare, including telehealth, should be thought of differently than the more conventional goods and services now bought and sold on the internet. Our current approach to healthcare – a combination of free market principles and government regulation – recognizes this difference and has long been considered acceptable. Why? Because the price of market failures, namely avoidable pain, suffering and death, is generally seen as unconscionable.

To be sure, internet deregulation may provide the financial incentive needed to more fully develop a robust and consumer-responsive telehealth infrastructure. Indeed, the rapid consolidation of the healthcare industry, combined with the growth potential of telehealth, will continue to attract the healthcare industry’s attention. The repeal of net neutrality will likely profit both healthcare companies and ISPs alike.

There is no guarantee that the new partnerships and financial gains brought on by the repeal of net neutrality will increase the value of America’s healthcare spending. Within healthcare industry, the results of the FCC’s repeal, combined with an already complex and inefficient healthcare marketplace, will be unpredictable at best. What seems most likely is an increase in corporate profits. It may be American healthcare consumer, however, who ultimately pays the price.

John McDougall, MD is a postdoctoral fellow with the National Clinician Scholars Program at Yale. 

 

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Connecting the Dots: Referrals between Medical Care and Community Resources

By JOELLE JUNG & VALERIE LEWIS

Policymakers and providers all agree that addressing patients’ non-medical needs will be critical to improving health, health care, and health care costs, but little progress has been made towards integrating traditionally segmented services. What can and should a health care organization do? Realistically, most health care organizations will not build new lines of social services into their core clinical operations. Instead, leading organizations are connecting the dots by optimizing referrals to existing community resources. Based on phone interviews and site visits with executive leadership, frontline providers, and community partners, we highlight the work of nine innovative health care organizations. Here, we offer practical steps to reflect upon where your organization stands and where it might look to be in a referral model for community resources.

Starting point: Does your team have a useful resource library?

Useful is the key word here: we’re not talking about a static laundry list that simply names local community resources on a website or a print out. Useful resource libraries not only catalog existing community resources but also include pertinent details such as eligibility criteria. For example, at one organization we interviewed, health coaches use their electronic resource library to match the patient’s age, income, and residence profile with available community resources. To create the most useful resource library for your organization, we suggest querying your care team about what essential pieces of information would help them effectively and confidently refer patients to community resources.

Importantly, a resource library is only as useful as it is accurate and up-to-date. Organizations will need to identify who will monitor and update the resource library at regular intervals by visiting program websites, calling program contacts, or surveying providers about their experiences with listed community resources. For example, one organization we interviewed created a dedicated committee to appraise over 300 community resources that engage with their providers. Clearly, modifications to the resource library are to be expected, so electronic resource libraries (e.g. in a cloud-based platform or in the EHR) will be more dynamic than binders. Two organizations we interviewed are even using or contracting with companies that have created web-based resource libraries (e.g. Aunt Bertha, NowPow).

Next step: Who is responsible for referring patients?

Remember, the resource library is a tool not the solution. Organizations must lay out what roles will best enable referrals to community resources. Depending on your unique organization, referrals to community resources might be done through an entire team, an individual, or outsourced partners. For example, one larger organization we interviewed developed multidisciplinary teams of nurses and social workers, making specialized referrals and handoffs for particular social service domains (e.g. a housing team, transportation team, and nutrition team). In contrast, another organization used a single, centralized point person to make all referrals into the local community. Alternatively, two organizations we interviewed piloted with external partners (such as Health Leads) whose staff executes the referrals to specific community resources.

In addition to defined roles, organizations must not forget to develop associated workflows. What is the workflow to identify the patients with social service needs? What is the provider’s workflow to connect with whomever will make the community resource referrals? Are there workflows in place to follow-up regarding the referrals made to community resources? While developing these workflows, organizations need to consider what the preferred modes of communication are and which documentation platforms will facilitate the workflows. For example, one organization we interviewed built workflows into their EHR by tailoring the existing social service pathways of the Pathways Hub Model to fit the organization’s particular patient needs, staffing structure, and provider network. By strategically designing roles and workflows that support patient referrals to community resources, your organization shares responsibility for the success of the referral model.

Final move: Are you evaluating the impact?

Evaluating your referral model is crucial not only to intelligently decide what to keep, drop, or adapt but also to assess the impact of your work. All of the organizations we interviewed found it challenging to demonstrate that referrals to community resources directly influenced larger outcomes such as total costs of medical care. More immediately, data points that organizations may want to capture include the number of patients with different types of social service needs and the number of complete and incomplete referrals made to each community resource. For example, one organization we interviewed is tracking their rate of unsuccessful referrals to community resources in order to reveal where gaps in the community persist and subsequently inform advocacy efforts.

Furthermore, evaluating your referral model sets the foundation to build a business case for social service partnerships. A few organizations we interviewed were interested in entering financial arrangements with a curated network of community partners based on quality and other performance metrics, although these were generally still in the early stages of development. As organizations look to harmonize data collection and evaluation efforts, partners will need to agree upon the types of data, preferred reporting formats, and interval of reporting requests. In fact, based on interviews with community partners, we learned that many community partners are motivated to collect and exchange data on shared patients in order to improve their value proposition with grant funders and secure future funding.

Following the lead of innovative organizations, there are valuable opportunities for health care organizations to use a referral model with community resources. Health care organizations that leverage their local communities can more effectively match patients with comprehensive services critical to improving health status. Improving the referral model is a key step in connecting the dots between medical care and community resources, a small move toward systematically caring for the whole person rather than the discreet set of problems bringing a patient into a given provider’s office.

The authors are health services researchers at Dartmouth.

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