The Health Care Blog

DNADirect bought by Medco: Consumer genomic counselling goes mainstream?

By Matthew Holt

Ryan Phelan started DNADirect to expand the power of genetic testing to everyone, using the Web. She’s been ploughing a tough furrow but been making some real progress in the last few years, including getting an investment from Lemhi Ventures and working with Humana to provide genetic testing to its members (and the utilization management going along with it), to go along with their initial DTC approach.

Late last week DNADirect was purchased by Medco. I spoke with Ryan and Robert Epstein, Chief Medical Officer of Medco to get just a taste of what this will mean for the future of DNA testing within Medco.

Here's the interview.

Gawande's "Checklist Manifesto"

By BOB WACHTER

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there's no such worry here: Atul's passion for patients and humility are so obvious that one never questions his methods or motives.

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EHR Redux

By DAVID C. KIBBE

It's time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, "meaningful users of certified EHR technology."

While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs.

The revolution in the marketplace, if it occurs, will come from the changes to EHR technology blueprinted in the IFR, regardless of when, which, or how many doctors and hospitals become meaningful users. Let me explain.

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How to Get Enough Votes in the Senate

By PAUL LEVY

When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.

What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways -- to Nebraska, to Louisiana, to the labor unions -- to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn't like what they had been seeing.

Now, it may be that the Republicans will act to kill anything that might come along. I don't think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?

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Government to Account For More Than Half of Healthcare Spending

By MERRILL GOOZNER

Amid all the gloomy numbers in the latest government projections for health care spending, one statistic stands out: Public sector involvement in health care this year will surpass private sector spending for the first time in U.S. history. 

The actual projections show it will only reach 49.3% of $2.57 trillion, but that assumes Congress won't throw more money at physicians at the end of this month when previously legislated cutbacks in Medicare pay are slated to go into effect. Congress can't pass health care reform, but spending more on physicians (mean salary for cardiologists and radiologists in 2009 was over $400,000) has unusual bipartisan support.

What's driving the growing public role is no mystery. With unemployment at 10 percent and underemployment widespread, millions of Americans have lost employer-based coverage and now must rely on public sector programs. Even where people remain employed, their firms can no longer afford skyrocketing premiums and thus are abandoning or cutting back on coverage.

And there's no end in sight to those trends, even with an improving economy. Health care spending, which surged to 17.3% of gross domestic product in 2009 from 16.2 percent in 2008,  the largest single jump in the history of government recordkeeping, is slated to rise to 19.3% in 2019, a year when the public sector will account for 51.9% of the $4.49 trillion health care economy. And that's without paying physicians more.

Here's another way to look at it: In 2019, U.S. government agencies at the state and federal level ALONE will spend 10% of GDP on health. That's a greater share of economic activity than many other highly industrialized nations that insure everyone, yet the U.S. will still have one in six or seven people without any coverage at all at some point during the year.

Why Calculators Are the Future of Healthcare

By THOMAS GOETZ

Want to know the future of medicine and healthcare in one sentence?

 For my money, it goes like this: The real opportunity in healthcare is to combine our personal data with the huge amount of general biomedical and public health research, in order to create customized information that’s specific to our person and our circumstance. We need relevance, and the right information at the right time will help us make better choices for prevention, helping us stay healthier longer, it’ll help us navigate diagnosis, letting us select screening tests that are useful and not unnecessarily fearful, and it’ll let us make better decisions on care and treatment – when we’re trying to choose among various treatments to find our way back to health.

It’s in the last category – care and treatment – that I wrote a recent post at the Huffington Post about one man’s story with prostate cancer. Tom Neville got a diagnosis and then had to struggle to find information to help him make sense of what to do. Ultimately, he chose surgery, but the difficulty of the choice led him to create Soar Biodynamics, a company that offers decision-making support for men assessing their prostate health.

You can read his story here and learn more about his tool here, but for the purposes of this post I wanted to consider the kind of decision-making tool he created. It’s called a nomogram, and it’s one of my favorite discoveries in researching The Decision Tree.

A nomogram is basically a calculator – a way to assess our risk or outcome for a particular condition. A nomogram starts with an interface where a few telling datapoints can be entered, and then turns to an algorithm that crunch those numbers together with broader data about the condition. The result is a statistical prediction – the prediction can concern the outcome of the disease, or it can be a recommendation for particular treatment (a medical nomogram is not to be confused with mathematical nomograms, which are tools for calculating geometrical something or others).

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Wellpoint's wasted opportunity

By Matthew Holt

Sometimes with something so egregious gets written that, even if it’s in the Wall Street Journal, you have to notice it. Angela Braly, the CEO of Wellpoint—compensation a hair under $10m in 2009—ought to be happy, even though Joseph Rago in the WSJ is surprised about that. It looks like the health reform bill which put much of Wellpoint’s highly profitable individual and small group business at risk is dead, and this week Wellpoint started putting up rates between 35% and 80% in the California market (where it’s Anthem Blue Cross).

But the WSJ quotes her as calling health reform a “wasted opportunity”. Funnily enough Wellpoint and the trade association it funds, AHIP, were on both sides of the debate. Pushing Congress to give it 30 million more customers as part of the bill, and then surreptitiously funding the Chamber of Commerce to oppose health reform (and putting pressure on the Blue Dogs, and the DINOs in the Senate) when some of the terms of the House Bill started to look less favorable (85% Med loss ratios limits among them).

I’d had some semi-decent hopes for Braly and her team.

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The point of Health 2.0. Yes there is one

By Matthew Holt

The (not huge) world of Health 2.0, participatory medicine and ePatients has been fretting itself about a comment Susannah Fox (all hail) elevated into a post called “What’s the Point of Health 2.0”.

Here’s an excerpt from the comment from DarthMed,

The remaining 95% of “patients” out there are not motivated to become informed, or invest the time/energy/money in using any of these tools. These are the folks that know that fast food isn’t healthy, but are just too tired to choose differently. Some (emphasis on some) will do a standard google search when they receive a new diagnosis at best. Yet these are the folks – often folks with multiple chronic (often preventable) health problems, many overweight, on multiple medications, sometimes social problems – that have the real issue that needs fixing.

So we can all sit and perfect the tools for a few folks that never needed them anyway, or we can recognize that the kinds of solutions required for healthcare in the US today have nothing to do with fancy IT, or prioritization on search engines, and everything to do with low-tech, unsexy approaches toward grass-roots public health. Sorry to be the voice of reality guys.

and here’s (an excerpt) from another DarthMed made on Fard Jonmar’s blog.

Today we are looking at millions being pumped into health-app start-ups, none of them profitable (or nearly profitable). Billions being pumped into linking electronic health records that ePatientDave showed us can be quite inaccurate anyway (given his GHealth uploading experience, albeit with claims data). So, after a few billion dollars of public and private investment we will have some iPhone apps that “self-informers” will use, a few “vibrant” patient communities of 10,000 patients with only 1,000 patients active (does anyone hear the sound of “disruption” here?), and a vaguely interconnected network of health information space junk.

OR, we legislate that patients should be entitled to receive within 24 hours of demand a one page health summary from their doctor + a copy of test results that they ordered and scripts that they wrote in the past 12 months, and leave it up to the clinics to work out how they deliver on it. Period. Then, lets use the billions left over, and our passion to do more diabetes screens in schools, factories; more mammograms; more childcare for teenage moms so they can go to school/college; more after-school activities to promote fitness and wellbeing at an age where behavior modification can make a big difference.

Unfortunately most Health 2.0 debate revolves around defending new technologies as the solution. And in the process, we’re missing the main point that many preventable social and health problems are just festering away. When technologies are the answer, they take off by themselves (case in point, Google Maps vs Google Health). And I’m sorry, but the HIT horse has been whipped and crying, trying, dying for years.

I'm a little baffled by both of darthmed's comments.

Yeah, it's hard to change behavior. Yeah, it's a good thing to have more preventative and primary care.

But Health 2.0 communities and tools are clearly helping patients and saving lives here and abroad. And there's oodles of research from Kate Lorig/David Sobel and lots of others that online (and offline) support groups help patients achieve better outcomes at lower costs.

So is the complaint that spending on building Health 2.0 technologies is crowding out spending that should go to preventative care?

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Plan B

By ROBERT LASZEWSKI

With word that the House is likely to take up the repeal of the health insurance industry anti-trust exemption it  is now clear the Democratic leadership has begun Plan B.

It is also clear that this is much more a part of a political Kabuki dance then any substantive effort at even piecemeal health care reform.

The House probably has the votes to pass the repeal. The Senate does not. I doubt that even all of the 59 Senate Democrats will vote for it if and when it does come up on the floor of the Senate.

The base of the Democratic Party, as well as many “progressive” Dems in the House and Senate, are rabidly mad about not being able to ram their health care bill through. That is why you continue to hear all of the talk about reconciliation options even though there is no chance such a scheme would pass either the House or Senate.

But what to do? The apparent answer is to bring up a few smaller health care bills the Democratic leadership views as popular back home and expect the Republicans will vote against them. Right now health care is a big negative issue for the Dems given the unpopularity of their effort to date. But if they can be seen trying to pass a few smaller measures “we can all agree on” only to be thwarted by Republican opposition their hope is they can turn the table on this issue to their advantage—well before they get to November.>

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Autism and the MMR: Finally a Retraction

By NAOMI FREUNDLICH

Are we finally ready to close the door on the much-disputed link between the MMR vaccine and autism?

On January 30, Britain’s General Medical Council ruled that Andrew Wakefield, a gastroenterologist, had acted “dishonestly and irresponsibly” in conducting his research that established a link between autism and the MMR vaccine. And yesterday, the British medical journal Lancet finally retracted the resulting 1998 study authored by Wakefield that helped drive MMR vaccination rates in the U.K. down to the point where in 2008, measles was officially declared “endemic” in the country.

The Lancet’s editor, Richard Horton, told The Guardian "It was utterly clear, without any ambiguity at all, that the statements in the paper were utterly false," he said. "I feel I was deceived."

The GMC investigation, entailing 197 days of evidence, submission and deliberation  between July 2007 and January 2010, exposed an unscrupulous researcher who falsified data, used sloppy laboratory techniques and subjected children to painful and potentially harmful medical tests like lumbar punctures and multiple colonoscopies to try and prove his notion that MMR vaccinations cause bowel disease and autism. Wakefield even went so far as to offer children attending his son’s birthday party £5 to donate blood samples.

The investigation of Wakefield and his shoddy and unethical research methods began in 2004 when British journalist Brian Deer began talking with parents of the 12 children involved in Wakefield’s study and reviewing medical records. Since then, Deer has dedicated countless hours and words to setting the record straight about Wakefield’s work—including the finding that his research was funded by lawyers representing parents who planned to sue vaccine makers for damages.

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American Healthcare: Caught in a Bad Romance

By Ian Morrison

“I want your Ugly.  I want your Disease
I want your Everything, as long as it’s Free.”

—America’s leading contemporary philosopher, Stefani Germanotta (aka Lady Gaga)

Insight comes from unlikely sources. Lady Gaga nailed the health reform dilemma. We have a healthcare delivery system that is an orgy of profligacy and excess that offers the false promise of making ugliness, disease and death all optional. And, we the public love all of it, as long as it’s free, at least to us as individuals. We want high tech, high quality, high expectations met, highly trained professionals delivering high standards, paid by someone else. And the magic fairy that will pay for all of this? Health insurance. Give everyone an insurance card and they can have their everything and it will be free, or close to it. 

But wait, isn’t the cost of insurance tied to the costs of care? Doesn’t the sum of all healthcare costs for a covered population (plus administrative costs) divided by the number of people equal the premium. Doesn’t the premium come out of my pocket as taxpayer, employee or individual? How can I have everything, as long as it’s free? 

Short answer is: you can’t.

We are caught in a Bad Romance with healthcare.

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Healthcare: Right or Responsibility?

By Stephen C Schimpff, MD

During the presidential debates, Tom Brokow asked, “Is healthcare a right, a privilege or a responsibility?”The candidates did not answer the question, but now would be a good time for Congress and the Obama Administration to balance the rights being offered as part of reform with corresponding responsibilities.

We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don’t work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed - unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests - all of which lead to higher total costs of care.

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The Health Assurance – Disease Insurance Plan

By NORTIN M HADLER, MD

The American health care delivery system is reprehensible for the degree to which it tolerates the under-treatment of those in need and supports the over-treatment of those who are entitled. It invests vast wealth in its own entropy. I don’t want to belabor all this shamefulness. The best we can do is to superimpose rationality on the current system—iron clad, science supported, and patient driven rationality with the goal of assuring health and providing recourse when that assurance falls short. We are advantaged by a cadre of physicians who are culled from the ranks of the best and the brightest and who would like nothing better than to do what is right by their patients. The moral charge to our society is to design a system that exists for no reason other than to provide for the wellbeing of both the sick people and the sick peoples amongst us¹. To begin to do so demands confronting 3 of the current system’s most intransigent and least recognized moral lapses: licensing overtreatment, institutionalizing conflictive relationships, and promoting perverse incentives.

Failing #1: Putting the Health Care Cart in Front of the Health Care Horse

In the debates regarding health care reform, one goal promoted by all is “quality.” If only we could perform up to standards, the institution of American medicine would be supreme and vindicated. That being the case, why is it that eliciting “quality” in the treatment of heart attacks with carrots and sticks does not improve outcome?² I argue that the American approach to coronary artery disease is unsurpassed in terms of Type II medical malpractice, my term for doing the unnecessary even if it is done very well.

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Coming Short with Thinking

By ROB LAMBERTS

I am mad at congress.

I don’t care if they are Democrats or Republicans, I am sick of healthcare being treated as a political football. How much more of a crisis do we need before we actually start working on a solution? Why does each party have to sit on its side of the aisle shooting spitballs at the other? Each side has its pet issues that are tied to contributors, supporters, and lobbyists. Each side will work to see the other side fail even if the other side is right. Each side seems unable to do anything unless there is political value in it. Power is more important than service, and power is a short-term project.

The real problem is that congress is thinking of short-term political gain while sabotaging the long-term. It’s like the publicly traded company that works to maximize quarterly profits even if it damages the corporation in the long run. Our society thinks in the short not in the long, and our congressmen are doing so in a way that harms all of us.

I thought of this while I was in the shower this morning. I am not sure if it is the shampoo, but I have thoughts about blog posts while I’m in the shower. I was getting filled with righteous rage about the stupidity of congress and how they mimic corporate America in short-sightedness.

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Todd Park speaks: Free the data!

By Matthew Holt

Todd Park is definitely one of health care IT’s good guys. Todd was the brains (though not the mouth!) behind athenahealth. After he left athenahealth, he spent a year back in California doing angel investing (Ventana among others) and being a dad. But despite his desire to stay on the west coast, he was dragged into the vortex known as Washington DC, and for the last 5 months he’s been the (first) CTO of HHS. (By the way, he cashed out his investments, and politely turned down my proposal to “care for” his cash while he was being a public servant!)

Todd gave the keynote yesterday at the Health IT Summit for Government Leaders. He describes his job as unlocking HHS’ “inner mojo” in terms of data use and technology innovation. So what are the big deals he sees? These are my notes on his fast talking!

1) HITECH/ARRA is not about for paying for software. Its purpose is to incentivize “meaningful use”. He wants to make sure that people understand that the NHIN (National Health Information Network) is not a thing. It’s a set of policies and services that people can use to make health data work over the Internet. It is NOT a parallel network. And at the end of the day, what’s going to make this work is the private sector — including vendors modifying their products to match these policies.

2) Leveraging the power of HHS data for public good. The amount of data HHS has is “ridiculous”. It has a set of sets of data. Todd is a paid up member of Tim Berners-Lee “free the data” club. They’re adding all kinds of data sets to data.gov including every grant, patent et al licensed/paid for by HHS. Todd calls this “data liberation”. They’re also creating community health maps where data on community health performance can be mashed up with other types of maps (real estate, job listings, et al). In addition, they’re doing “smart targeting” — an attempt to combine findings from different/disparate data sets without waiting to do the big database integration. He’s hoping to use techniques that the intelligence community uses to link, say, emails and bank wires, to similarly track, say, disease outbreaks, drug interactions, etc.

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Simple Steps to Meaningful Health Reform

By KIM BELLARD

 Now that health reform at the federal level seems to have hit an impasse, Congress and the Administration are scrambling to see if anything can be salvaged this year.  Although both the House and Senate bills are severely flawed, each falling short both on true health reform and on fiscal responsibility, it would be a shame if we walked away from these efforts with nothing to show for it.

Doing something about those “evil” insurance companies remains a primary target, with brave talk still coming out about removing the ability of health insurers to consider pre-existing conditions in accepting new applicants. 

This singular focus ignores two important facts - first, that this problem is primarily in the individual market, since such use of medical underwriting/preexisting conditions exclusions is largely absent from the predominant group health insurance market, and second, that such restrictions will inevitably lead to higher costs.  The latter statement is not fear-mongering; it is Economics 101. 

When people come into the insurance risk pool who have, on average, higher costs than the rest of the pool, the average costs of the new pool will be higher.  I.e., premiums go up.  The only way around this is to bring in lots of people with below-average costs to subsidize the higher cost entrants, and without either mandates or subsidies this won't happen.

Fortunately, there are several meaningful reforms that could be put into place that, while not achieving a full reform, could go a long way to addressing some of the most serious problems.  Here are some:

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10 Insights on the iPad

By Douglas Goldstein

The iPad got it right and will set the standard for a new and improved way to enjoy our connected lifestyle. The iPhone blazed the way as it shifted mobile phones from something to talk on…to powerful multi-app platforms that solve many problems and just happen to make phone calls, too.

The iPad and soon many similar devices will revolutionize the way we experience life and work from newspapers, t.v. and movies to fitness, personalized health and medical services. Here are 10 insights for delivering person- centered fitness, health and health care inspired by the iPad, iPhone and iPod Touch from Apple, the world’s leading MD (Mobile Device) company.

1. Keep it Simple The iPad, like the iPhone before it, is so easy to use it is instinctive – as if coded into our social DNA. Over 75 million iPod Touch and iPhone customers have trained on it – most without ever opening a manual.

2. Power to the People – The iPad delivers another amazing device that solves people’s problems. Healthcare, despite the rhetoric, continues to have a wholesalers’ mentality. But, with this device, people become empowered to take fitness and healthcare into our own hands, literally. Sometimes we act as consumers and other times we have to be the patient. This device allows for and understands our many differing needs and is able to offer guidance and connections via apps and games to show us the way.

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Collecting Patient Info in Haiti Using the iPhone

Dr. Elizabeth Cote, from Harvard Humane Initiative collects patient data at Fond Parisien, Haiti using iPhone and iCharts from www.CareTools.com. The developers were kind enough to customize the form in less than a week to support fields and info required to comply with international disaster data collection standards. HT / Dr. Enoch Choi

Medical Experts Say Haitians Will Need Health Care Help for Years to Come

By POOJA AWATRAMANI

The BBC recently reported that medical organizations with members serving the Haitian communities affected by the earthquake on January 12^th warn that one of the larger issues for Haitians will likely be the need for increased medical supplies, such as prosthetic devices and rehabilitation services.

Concerned about infection, doctors in Haiti have had to amputate the limbs of a great many injured patients. In addition to the need for such resources as medical devices and prosthetic equipment, doctors are also still in need of simple medications. Antibiotics are needed to prevent the spread of infections and painkillers to help damaged patients simply make it through the day.

Because many of the country’s hospitals were also destroyed by the earthquake, doctors in Haiti are performing most care in makeshift open areas. And in such environments, infection spreads fast. Though the few hospitals that are running are reported to be in relatively well-organized condition, many of the patients in those hospitals are not leaving as they have nowhere else to go, except perhaps the streets– where infections await their open wounds. So they stay, Doctors are left with fewer and fewer areas to treat, and the number of patients increases. To remedy the situation, there are plans at present to quickly build a convalescent center.

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Check Lists and Decision Trees versus Spontaneity and Imagination

By KENT BOTTLES

The task of health care reform in 21^st century America is to decrease per-capita cost of care and to increase the quality of care delivered to patients. It’s complicated.  A famous Rand study concluded that Americans only receive 55% of the care that science dictates. Patients intuitively believe that more health care is always beneficial. Medicare reformers would like to do comparative effectiveness research so that CMS and private insurers could wind up paying only for therapy that actually works. Some estimate that 30% of all care delivered in the United States is waste.  What some call waste, others label revenue, and Atul Gawande becomes famous for identifying waste/revenue in McAllen, Texas (http://bit.ly/ENlli).

Neuroscience tells us that the smartest human can only keep track of seven variables at one time, and physicians tell us that diagnosis and treatment of a complicated patient can involve as many as 100 such variables.  Computers are good at cataloging, organizing, and retrieving information, but physicians are not yet routinely utilizing them at the point of care.  Computers are also good at allowing us to analyze large data sets and learn from experience.   Patients yearn for the warmth and caring of a doctor who really knows and cares about them. Behavioral economics pioneered by Amos Tversky and Daniel Kahneman taught us that human brains are designed with inherent biases that make us less than rational decision-makers.  We now know that human physicians and patients suffer from biases such as Pygmalion complex, confirmation bias, focusing illusion, incorrectly weighing initial numbers, and being more impressed with single cases than conclusions based on large data sets (http://bit.ly/49q4Uy).

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Uwe and Heritage agree: we need a tax-funded universal pool

By Matthew Holt

When you’re at a party and someone explains to you that they just read a great article in the NY Times explaining why Peggy Noonan doesn’t understand basic math, and you know that they’re referring to Uwe Reinhardt, then you’re over-wonked. That’s surely my condition

Here’s what Uwe said—you can’t just ban medical underwriting as Noonan suggested, because the individual insurance market will collapse. Both the history of New Jersey (and Washington state) in the 1990s, and in current Massachusetts where people can buy insurance or pay a lesser fine, show that healthy people won’t buy insurance until they need it.

The answer is to force everyone into a universal insurance pool

But of course, that means younger and healthier people will likely pay more. For the good folks from Heritage writing on the WSJ Opinion page this is an outrage. Using their complex model they came up with the amazing analysis that if you give uninsured younger people with no health condition the choice of paying a smaller fine or a higher premium—surprise surprise—most will pay the fine. And of course that’s exactly what’s happened in Massachusetts.

The problem is of course that most younger people who have no insurance are in low wage jobs, They therefore place a much higher value on receiving money now than forgoing it to later stave of a potential risk of catastrophe from having no insurance

So we deal with this in a very sensible way in the rest of society’s transactions.

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Regional Variation Revisited: Price Differences Not A Significant Factor

By MERRILL GOOZNER

Dartmouth scholars have revisited their analysis of regional variation in health  care spending and found contrary to the assertions of some critics that cost-of-living differentials do not account for much of the difference. However, they confirmed that some big cities with high poverty concentrations that also serve as training grounds for future physicians may have been unfairly lumped in with areas that overuse health care services.

The new study in Health Affairs showed after adjusting for price differences that Miami, Florida and McAllen, Texas still led the pack in terms of how much Medicare spent on each beneficiary. Both areas still spent nearly three times more than the lowest spending regions of the country, which remained Honolulu, Hawaii and LaCrosse, Wisconsin. 

There were a few areas of the country where the adjustments made a big difference, and they were mostly big cities. The Bronx and Manhattan in New York City fell 39 and 33 percent, respectively, from the adjustments. But price was only a minor factor, according to the researchers, who were led by Daniel Gottlieb of the Dartmouth Institute for Health Policy and Clinical Practice.

Much of the reason why the New York metropolitan area is so costly is not because of the wage index per se (what we usually think of as "cost-of-living" adjustments), but because the CMS pays hospitals in the New York area so much to reimburse them for graduate medical education and caring for disproportionate shares of low-income patients.

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Cost, Choice, and Value

By JOHN V. JACOBI

The Massachusetts Massacre has everyone stepping back a bit. The President says that we should “coalesce around those elements of the package that people agree on,” but it is unclear just which elements those might be, given the extreme polarization that has defined the debate. He suggests that points of agreement might center on insurance reform and cost containment, which are both important goals. I’m skeptical that a sudden flowering of bipartisanship will allow such agreement, however. Ezra Klein, on the other hand, has a paring proposal that goes in another direction, and reminds us of why we got into this in the first place: to extend coverage to the uninsured. If we must narrow our focus, Klein says we should extend Medicare to those over 50, and expand Medicaid to those under 200% of poverty. This would get lots of people insured, and could well be accomplished through budget reconciliation if no Congressional coalescing is to be had.

However the parsing, paring, and palavering goes, cost control is and will be at or near the health reform debate for years to come. Two recent articles are worth a look for those interested in analysis of cost-containment strategies.

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The Cost of Fear

By ROB LAMBERTS

I was talking to a fellow physician about a mutual patient. I had information  that would help him in their  care and he was taking the unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a thought: “I could email you those documents much easier.  Do you have an email address?”

Silence.

After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email.  The palms sweat, the speech stumbles, and the awkwardness is thick in the air.  It’s as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult.  There is a culture of fear in our healthcare system; it’s a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger.  Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them.  They see it as a collar on their neck that they only wear because others are stronger than them.

It’s the only reason I can see for the resistance of a transforming technology.  It’s the only way to explain how they would favor a non-system that hurts their patients over a system that can improve their care immensely.  After all, what good is it to embrace a technology – no matter how good – if it will take away their ability to practice medicine?  ”It’s good for you!” they hear from politicians and academics, but they see it as a poison pill.

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The Info-Button Standard: Bringing Meaningful Use to the Patient

By DON KEMPER, CEO HEALTHWISE

Regardless of the U.S. administration’s “meaningful use” requirements, if health information technology (HIT) is to become meaningful for patients, it must include the prescription of information and tools to help each patient better manage his or her own care.

Ask patients what they want from HIT systems, and they will tell you three things:

- “Tell me my diagnosis, what will happen, and what I can do myself to better manage the problem.”

- “Tell me my medical tests results and what they mean to me.”

- “Tell me my treatment options, and help me participate in the treatment decisions.”

The soon-to-be-finalized HL7 International Context-Aware Information Retrieval standard (nicknamed the HL7 “Infobutton” standard) makes it far easier for providers of electronic health records (EHRs) and personal health records (PHRs) to deliver just what the patient wants. And that is what will put the meaning into meaningful.

Using the HL7 Infobutton Standard for Information Prescriptions

The HL7 Infobutton standard has been widely adopted since 2007. It facilitates the delivery of a set of standardized information about the patient, the provider, and the activity of a specific care encounter or moment in care. An Infobutton manager (or equivalent) accessed by an EHR application can then pull from that set the information it needs for any relevant use case. In most cases the Infobutton has been used to bring up decision support information for the clinician.

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