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Friday, August 9, 2013
Thursday, August 8, 2013
We Can Learn About the Difficulties of Healthcare Reform from the Health Problems of Former Presidents
One of mantras of those who oppose healthcare reform is that it will deny people needed care. Programs that require measurement of healthcare quality or aim to discourage overuse of care are viewed by some as efforts to deny Americans their rightful access to healthcare. Consumers want "choice" to get the care they believe they need, and much of the healthcare system is well-configured with the financial incentive to meet that need.
This week, former President George W. Bush underwent a coronary stent procedure to open up a 70% blockage in one of his coronary arteries. The details of his symptoms are unclear but, as noted by an article in Forbes magazine [1], if President Bush was not having cardiac symptoms (e.g., chest pain), then there is no scientific evidence that the stenting procedure he underwent will prevent a future heart attack or prolong his life compared to just using optimal medical therapy (e.g., treatment of hypertension, hyperlipidemia, etc.) [2].
President Bush is not the only former President to have had possibly suboptimal healthcare for heart disease, which is still the top killer of Americans. President Bill Clinton also had heart problems, although he was acutely symptomatic and required urgent treatment. President Clinton was in suburban New York at the time and went to the nearest emergency department. This hospital had a referral arrangement with Columbia-Presbyterian Medical Center (CPMC) in New York City, where the former President was transferred. It turns out that CPMC, as great an academic medical center as it is, had poor performance on a number of quality measures in the New York State Cardiac Surgery Reporting System, a system whose data has been shown to be associated with beneficial clinical outcomes [3]. Even worse, the surgeon who operated on the former President had a worse-than-average rate of complications.
President Clinton did suffer a complication, and we cannot know for sure whether the complication was a result of the poorer quality care provided by his hospital or surgeon. But as noted in an article in Slate [4], this does raise questions as to the limits of consumer-driven healthcare. If two former Presidents, who presumably have more access to resources and information than anyone else on the planet, cannot make optimal healthcare decisions, can we expect the average consumer to do so? Of course, cardiac disease is one of those conditions for which we have more studies and more quality data than almost any other, and it gets worse from there.
It is unfortunate that a combination of politics and financial self-interest have created a climate of equating any attempt to rein in unnecessary healthcare as "denying" someone care. Focus groups of consumers show there is widespread skepticism, based on misunderstanding, of terms like "quality guidelines" and "evidence-based care" [5,6]. Efforts to have Medicare reimburse physicians for consultation about end-of-life care become "death panels" [7], the Politifact lie of the year for 2009. Efforts to be more appropriately evidence-based about the use of mammography in younger women were viewed as evidence of government malfeasance, when it reality more effective mammography would save the government money if they it led to improved treatment outcomes for breast cancer [8].
I certainly support patient engagement in healthcare decisions. I applaud the "Choosing Wisely" initiative of leading medical societies to highlight care that it is ineffective or outright dangerous [9]. But I remain, like many, frustrated that our political landscape and healthcare financing system impede a forthright discussion of the facts.
References
1. Husten, L (2013). Did George W. Bush Really Need A Stent? Forbes, August 6, 2013. http://www.forbes.com/sites/larryhusten/2013/08/06/questions-about-president-george-w-bushs-stent/
2. Stergiopoulos, K and Brown, DL (2012). Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Archives of Internal Medicine. 172: 312-319.
3. Jha, AK and Epstein, AM (2006). The predictive accuracy of the New York State coronary artery bypass surgery report-card system. Health Affairs. 25: 844-855.
4. Sanghavi, D (2009). Talk to the Invisible Hand - The promises and perils of treating patients more like consumers. Slate, September 28, 2009. http://www.slate.com/articles/news_and_politics/prescriptions/2009/09/talk_to_the_invisible_hand.html
5. Carman, KL, Maurer, M, et al. (2010). Evidence that consumers are skeptical about evidence-based health care. Health Affairs. 29: 1400-1406.
6. Ross, M, Igus, T, et al. (2009). From our lips to whose ears? Consumer reaction to our current health care dialect. Permanente Journal. 13(1): 8-16.
7. Nyhan, B, Reifler, J, et al. (2013). The hazards of correcting myths about health care reform. Medical Care. 51: 127-132.
8. Quanstrum, KH and Hayward, RA (2010). Lessons from the mammography wars. New England Journal of Medicine. 363: 1076-1079.
9. Cassel, CK and Guest, JA (2012). Choosing wisely: helping physicians and patients make smart decisions about their care. Journal of the American Medical Association. 307: 1801-1802.
This week, former President George W. Bush underwent a coronary stent procedure to open up a 70% blockage in one of his coronary arteries. The details of his symptoms are unclear but, as noted by an article in Forbes magazine [1], if President Bush was not having cardiac symptoms (e.g., chest pain), then there is no scientific evidence that the stenting procedure he underwent will prevent a future heart attack or prolong his life compared to just using optimal medical therapy (e.g., treatment of hypertension, hyperlipidemia, etc.) [2].
President Bush is not the only former President to have had possibly suboptimal healthcare for heart disease, which is still the top killer of Americans. President Bill Clinton also had heart problems, although he was acutely symptomatic and required urgent treatment. President Clinton was in suburban New York at the time and went to the nearest emergency department. This hospital had a referral arrangement with Columbia-Presbyterian Medical Center (CPMC) in New York City, where the former President was transferred. It turns out that CPMC, as great an academic medical center as it is, had poor performance on a number of quality measures in the New York State Cardiac Surgery Reporting System, a system whose data has been shown to be associated with beneficial clinical outcomes [3]. Even worse, the surgeon who operated on the former President had a worse-than-average rate of complications.
President Clinton did suffer a complication, and we cannot know for sure whether the complication was a result of the poorer quality care provided by his hospital or surgeon. But as noted in an article in Slate [4], this does raise questions as to the limits of consumer-driven healthcare. If two former Presidents, who presumably have more access to resources and information than anyone else on the planet, cannot make optimal healthcare decisions, can we expect the average consumer to do so? Of course, cardiac disease is one of those conditions for which we have more studies and more quality data than almost any other, and it gets worse from there.
It is unfortunate that a combination of politics and financial self-interest have created a climate of equating any attempt to rein in unnecessary healthcare as "denying" someone care. Focus groups of consumers show there is widespread skepticism, based on misunderstanding, of terms like "quality guidelines" and "evidence-based care" [5,6]. Efforts to have Medicare reimburse physicians for consultation about end-of-life care become "death panels" [7], the Politifact lie of the year for 2009. Efforts to be more appropriately evidence-based about the use of mammography in younger women were viewed as evidence of government malfeasance, when it reality more effective mammography would save the government money if they it led to improved treatment outcomes for breast cancer [8].
I certainly support patient engagement in healthcare decisions. I applaud the "Choosing Wisely" initiative of leading medical societies to highlight care that it is ineffective or outright dangerous [9]. But I remain, like many, frustrated that our political landscape and healthcare financing system impede a forthright discussion of the facts.
References
1. Husten, L (2013). Did George W. Bush Really Need A Stent? Forbes, August 6, 2013. http://www.forbes.com/sites/larryhusten/2013/08/06/questions-about-president-george-w-bushs-stent/
2. Stergiopoulos, K and Brown, DL (2012). Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Archives of Internal Medicine. 172: 312-319.
3. Jha, AK and Epstein, AM (2006). The predictive accuracy of the New York State coronary artery bypass surgery report-card system. Health Affairs. 25: 844-855.
4. Sanghavi, D (2009). Talk to the Invisible Hand - The promises and perils of treating patients more like consumers. Slate, September 28, 2009. http://www.slate.com/articles/news_and_politics/prescriptions/2009/09/talk_to_the_invisible_hand.html
5. Carman, KL, Maurer, M, et al. (2010). Evidence that consumers are skeptical about evidence-based health care. Health Affairs. 29: 1400-1406.
6. Ross, M, Igus, T, et al. (2009). From our lips to whose ears? Consumer reaction to our current health care dialect. Permanente Journal. 13(1): 8-16.
7. Nyhan, B, Reifler, J, et al. (2013). The hazards of correcting myths about health care reform. Medical Care. 51: 127-132.
8. Quanstrum, KH and Hayward, RA (2010). Lessons from the mammography wars. New England Journal of Medicine. 363: 1076-1079.
9. Cassel, CK and Guest, JA (2012). Choosing wisely: helping physicians and patients make smart decisions about their care. Journal of the American Medical Association. 307: 1801-1802.
The Dirty Mac - John Lennon Keith Richards Mitch Mitchell Eric Clapton
Wednesday, August 7, 2013
Insights on Delaying Obamacare's Employer Mandate: Four Potential Unintended Consequences?
Which is it?
Delaying the employer mandate for one year is simply more evidence of Obamacare's unworkable complexity, says detractors.
The delay is flexibility and democracy in action, says supporters.
The Disease Management Care Blog is troubled by how Congress and the Obama administration underestimated the complexity of the local implementation of a one-size-fits-all national health program. It also knows that the White House needs some Affordable Care Act (ACA's) elbow room.
To gain a better understand what's going on, check out this article appearing in the New England Journal.
Recall that the intent of the ACA was to preserve employer-based insurance while enabling individuals to access similar levels of coverage in on-line exchanges. Toss in some income-based subsidies on the upside along with IRS penalties on the downside, and the intended outcome is that millions of Americans will enter the national risk pools. That, in turn, should lead to premium drops and greater access to health care.
So what could be the impact of the delay?
First off, there's what won't happen. The authors estimate that 2014 will be business-as usual for the vast majority of persons with employer-based insurance.
But here's four things that could happen:
1. Approximately 5 million part-time workers may be closed out from access to their employer's insurance for another year. In addition, the $10 billion in government income from the $2000-per-worker) will be lost. Both these numbers are small potatoes in a trillion-dollar enterprise involving tens of millions of workers, unless, of course, you happen to be one of those workers.
2. Millions of employed full time workers will continue to take a pass on taking the paycheck deduction for their employer-based insurance. Whether they change their mind in 2014 will not depend on how hard their employers work to sign them up, but how aggressively the IRS pursues the individual mandate.
3. Attached to the employer mandate were regulations that would have forced employers with a workforce of greater than 50 persons to offer competitive (read "low") insurance premiums. Since that's also been delayed, employers and their employees who want insurance have an even greater incentive to access the on-line individual exchanges. Employers get to reduce their insurance costs while individuals get to take advantage of those upside subsidies. The employer-employee win-win arrangement could not only undercut employer-based insurance, but "triple" the Fed's subsidy budget.
4. The DMCB's physician colleagues are not immune either. There is emerging evidence that the individual exchanges are likely to offer "frugal" insurance plans. Early indications are that these plans will turn to the old tricks of restricted networks and low provider reimbursement levels. This could result in millions of newly insured persons further stressing an overloaded primary care provider network.
 |
| Look at we did! |
Delaying the employer mandate for one year is simply more evidence of Obamacare's unworkable complexity, says detractors.
The delay is flexibility and democracy in action, says supporters.
The Disease Management Care Blog is troubled by how Congress and the Obama administration underestimated the complexity of the local implementation of a one-size-fits-all national health program. It also knows that the White House needs some Affordable Care Act (ACA's) elbow room.
To gain a better understand what's going on, check out this article appearing in the New England Journal.
Recall that the intent of the ACA was to preserve employer-based insurance while enabling individuals to access similar levels of coverage in on-line exchanges. Toss in some income-based subsidies on the upside along with IRS penalties on the downside, and the intended outcome is that millions of Americans will enter the national risk pools. That, in turn, should lead to premium drops and greater access to health care.
So what could be the impact of the delay?
First off, there's what won't happen. The authors estimate that 2014 will be business-as usual for the vast majority of persons with employer-based insurance.
But here's four things that could happen:
1. Approximately 5 million part-time workers may be closed out from access to their employer's insurance for another year. In addition, the $10 billion in government income from the $2000-per-worker) will be lost. Both these numbers are small potatoes in a trillion-dollar enterprise involving tens of millions of workers, unless, of course, you happen to be one of those workers.
2. Millions of employed full time workers will continue to take a pass on taking the paycheck deduction for their employer-based insurance. Whether they change their mind in 2014 will not depend on how hard their employers work to sign them up, but how aggressively the IRS pursues the individual mandate.
3. Attached to the employer mandate were regulations that would have forced employers with a workforce of greater than 50 persons to offer competitive (read "low") insurance premiums. Since that's also been delayed, employers and their employees who want insurance have an even greater incentive to access the on-line individual exchanges. Employers get to reduce their insurance costs while individuals get to take advantage of those upside subsidies. The employer-employee win-win arrangement could not only undercut employer-based insurance, but "triple" the Fed's subsidy budget.
4. The DMCB's physician colleagues are not immune either. There is emerging evidence that the individual exchanges are likely to offer "frugal" insurance plans. Early indications are that these plans will turn to the old tricks of restricted networks and low provider reimbursement levels. This could result in millions of newly insured persons further stressing an overloaded primary care provider network.
Tuesday, August 6, 2013
The Top Ten Advances in the Reorganization of Health Care
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| Let the breakthroughs begin! |
Many of these successes caught the imagination of patients and doctors alike, which partially accounts for our collective societal hunger for more “big bang” medical advances. It's therefore no wonder that there was early credit for the "blank shots" of genomics, the electronic record and evidence-based medicine.
The Disease Management Care Blog doesn’t doubt that some breakthroughs (novel anti-cancer chemotherapies, the extension of human life-spans or a cure for spousal-induced DMCB deafness) are waiting just around the corner. These surprises are probably lurking outside the academic-media spotlight involving underfunded and contrarian scientists. They will come from unexpected directions.
Yet, that doesn’t mean that there haven’t been momentous changes in health care. There have been and, what's more, they've escaped the attention of the medical-industrial complex. That's because they have more to do with how health care delivery, thanks to the twin forces of the internet and consumerism, is being radically reorganized.
Think of it as the Decade of Healthcare Redesign. Ten elements of this Redesign include:
1. Downjobbing: many tasks that were restricted to highly trained specialists are increasingly being performed by non-physicians, patients and technology.
2. Social Media: patients can not only access the internet for information, they can use the internet to pool input and solicit personalized advice from like-minded individuals
3. Democratized Artificial Intelligence: In addition to social media, we’re on the verge of being able to remotely access AI to generate a reasonably accurate list of diagnoses, suggested tests and recommended do-it-yourself treatments that include the option of doing nothing.
4. The Decline of the Credential: while the academic-industrial complex will continue to churn out superbly trained physicians, massive on-line education will enable persons to gain a surprising level of lay-expertise.
5. Predictive Data Mining with Risk Stratification: we can’t afford to treat every person the same way. Analytics are already enabling individuals to understand which of their individual risk factors have the best ratio of actionability and pay-off.
6. Big Data and Concurrent Research: Going from analog/unique to digital/tabulated means that we can pool data and find correlations that lead to medical insight as fast as the fastest server and processor can crank the numbers.
7. Team-Based Care: Its impact at the bedside, in the operating room and in the primary care clinic is greater than the sum of its parts.
8. Remote Robotic Surgery: think of the World’s Best Surgeon being able to use ultra-fast satellite communication technology to wield surgical instruments from the other side of the country. Just so long as there’s in-person back-up near-by, wouldn’t you want that?
9. Medical Tourism: As the rest of the globe imports the best that western medicine has to offer minus the United States’ overhead costs, the cost of overseas air travel is no longer be an impediment to patients or insurers.
10 Big Government: For better or worse, Washington DC has its nose under the health care tent. In the unlikely event that Obamacare gets repealed, top-down diktats will forever be a part of the landscape. Get used to it.
Thank You Farzad
This morning, National HIT Coordinator Farzad Mostashari resigned. His letter to ONC staff was profound. As I read it, I felt a lump in my throat. He will be missed.How much do I respect him? I have not worn a tie since Y2K, except for a bow tie last year in honor of Farzad.
I started working with Farzad when he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project. I was an early champion of eClinicalWorks and Farzad unilaterally transformed that product from a good EHR to a population health tool.
As Deputy National Coordinator he brought operational rigor and a public health perspective to ONC.
As National Coordinator he brought energy, enthusiasm, and momentum to healthcare IT. He inspired, challenged, and influenced with informal authority, never a heavy hand. Hundreds of people volunteered to support his vision out of respect for his ideas and a sense that it was the right thing to do.
Some people seek fame and fortune. Some just want to make the world a better place. In all the years I've worked with Farzad, I've never sensed any self-interest. He has been mission driven.
Washington is a hard place to work. Some say that no one is your friend (except your dog). Hours are long, pay is poor, and travel is overwhelming. Burn out is hard to avoid when you've cleaned the Augean Stables and your only feedback is that you missed a spot.
Each of the national coordinators had a different style. David Brailer had the strong opinions that were necessary to establish a new federal office. Rob Kolodner led early technology efforts at time when the Bush administration offered limited funding for healthcare IT. David Blumenthal served as a noble statesman painting a vision for the HITECH program. Farzad was the implementer who turned the HITECH vision into policy outcomes by pure strength of will.
I believe Farzad will serve until the end of September. I'll do whatever I can to solidify the trajectory over the next two months so that the cadence of Farzad's strategic plan seamlessly transitions to the next national coordinator.
Monday, August 5, 2013
Which of These Four News Reports Is False? Insights from the Wacky World of Health Care Reform
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| Baron Von Munchhausen |
BtL has guests try to guess which of three funny stories is based on a real true news report. The DMCB thinks health care is so wacky that it'd be more challenging to guess which of the four stories below is false.
Unfortunately, if you win, getting the DMCB to put its voice on your home answering machine is unlikely to impress anyone. However, if you can pick out which story is a complete Munchhausenesque fabrication, you will deserve the respect of your friends and co-workers.
Ready to try to get some bragging rights?
+++++
Even doltish man-trolls know better than to try to organize an all-male blogging conference. Unable to reach out to that demographic, HHS Secretary Kathleen Sebelius did what's best: appeared before the annual "BlogHer" Conference in an appeal to women bloggers to tout the benefits of Obamacare. Her outreach supplements plans to rely on celebrities to help with a nationwide drive to increase enrollment through the insurance exchanges. Next up will be effort to recruit motor scooter owners to sport pro-Obamacare ads on the back of their helmets. Then it's on to asking members of the European Beret Society to host recruitment drives at their monthly chardonnay tastings.
Answer here.
+++++
Al Lewis and Vik Khanna condemned the wellness industry in a Wall Street Journal editorial when they proclaimed that "workplace programs don't work." They went on to say that they are "ineffective at reducing costs, lack support in the medical literature, are unpopular enough to require incentives and are occasionally even harmful." Yet, the Khanna On Health Blog's “workplace wellness consulting” page suggests the authors’ unique consulting insights can help potential customers “do wellness right.” Did the DMCB mention that both individuals are lawyers?
Answer here.
+++++
Writing in a separate issue of the Wall Street Journal, former Vermont Governor and Democratic National Committee Chair Howard Dean actually attacked Obamacare by criticizing its Independent Payment Advisory Board as a rate setting enterprise that is doomed to failure. Brazenly using Tea Party terms such as "bureaucrats" and "health rationing," Dr. Dean's liberal-progressive apostasy prompted ACA architect Peter Orszag to curiously opine in a separate article in Bloomberg that the argument favoring IPAB is that it will be a much better rate setting body than Congress. If this keeps up, even labor unions will start criticizing Obamacare.
Answer here.
+++++
While partisan blood continues to spill over Obamacare in Washington DC, there is much good news outside the beltway. It's been announced that the IRS will not only rely on self-reporting of income levels in setting premium subsidies. Even better, individuals who qualify for tax credits while buying their health insurance with the on-line exchanges will get a two-fer: 1) the option of applying the rebates to reduce their monthly premiums, and 2) confidence that there won't be any tax liability "claw backs" should their final income be higher than anticipated. Interest and penalties will be optional.
Answer here
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