flying cadeuciiMaking a decision requires you to compare tests/treatments that have been contrasted in researh studies to see if one over another results in improved chances of good outcomes. In a sense, medical decision making is a competition. To assess the competition, you compare the chances of outcomes, or results from groups of people taking different options. The comparison is a simple subtraction in the amounts of outcomes that occur in each studied group.

Subtracting results in a difference that is either a benefit (if better for you) or a harm (if worse for you). For nearly all decisions, however, the test/treatment that is better for disease outcomes (benefit) is worse for complications (harm). Comparing, then, results in the following possibilities:

The chances of outcomes associated with the condition you have and the tests/treatments available will be the same for all options. In this case, chose the cheapest option.

The chance of outcomes associated with the condition you have will be less with one option. That option provides added benefit

The chance of a complication caused by the test/treatment that adds benefit for the disease outcomes will be greater (harm).

Since the test/treatment that is better for you in terms of the disease you have will be, simultaneously, worse for you in terms of complications caused by that test/treatment, a trade-off of benefit and harm is required.

Hence, the definition of “works” is that:

A test/treatment works when you feel there is more to gain from the greater chance of better disease associated outcomes than there would be to lose from suffering the complications caused by your chosen treatment.

So, medical-decision-making is a competition between options and there is always some good to be balanced against some bad.

The balance of good and bad from your perspective is what makes one treatment work over another.

Robert McNutt, MD is a board certified internist in Clarendon Hills, Illinois. He is a Professor at Rush Medical College of Rush University.

some_1Today I am in Finland at the Vertical digital health accelerator, part of a really impressive network of accelerators and incubators in Helsinki. Tomorrow is the huge SLUSH festival at which I (plus Steven Krein of Startup Health) will be talking on Thursday. Today, I’m speaking and moderating a great seminar with excellent speakers at Vertical for the End Game.

The End Game
 is a thought leader seminar that finds answers to questions. The most insightful speakers from around the world will talk about digital health. Speakers include the Head of Health & Medical equipment division of Samsung France, the Head of Healthcare of Telia, and many others including Luis Barros VC expert from Boston.


The seminar is streaming live on on November 10th at 3pm Finnish time (8 am ET, 5 am PT) The video will also be available for later viewing.


Munia Mitra MD“Lawyers aren’t graded.”

“CEOs aren’t graded”

“How would you feel if I tracked every e-mail you sent and tracked how many people responded to them? You wouldn’t like that very much would you?”   

“The people who make EMRs. Why aren’t they graded?”

If there’s one negative I hear time and time again from doctors when the subject of quality measurement comes up, it’s this one near-universal complaint. The world is unfair, the cards are stacked against us.

As a specialist at a busy urban medical center I hear the complaints almost every day from colleagues and peers at other hospitals. We’re being singled out for unfair treatment:  They’re out to get us. It’s the world against the doctors.

Many of the so-called experts I’ve talked to at meetings around the country express disdain when the topic of physician resistance to quality improvement programs comes up.

But it shouldn’t be terribly surprising that the idea that one’s performance is being tracked can be seen as intrusive and threatening. The reaction is in many ways completely predictable.


One of the most important trends in healthcare today is the inexorable shift towards high-deductible health plans. Over the past few months, my colleagues and I have analyzed tens of millions of visits to practices using athenahealth’s practice management and EHR services to understand the impact that this shift is having.  We believe there are some reasons for providers and practice leaders to worry–the average patient obligation has increased by 20% over the past 4 years, and the number of patients carrying large balances is increasing as well.  We have also seen that practices’ ability to collect these obligations is highly variable.

Across our network, patient payments provide nearly one-fifth of physician income, with the median athenahealth provider failing to collect 30% of what patients owe.  And the situation is getting worse.  As the graphic below shows, patient deductible obligations are up 22% in the past two years–while commercial payments have grown only 4%.

athena networks

My colleagues and I have studied these trends, and we’ve identified a few things that top-performing practices do to ensure that they are able to collect the dollars that they are owed.  In fact, at every step of the collections process–from scheduling to follow-up months after a visit–top-performing practices take a different approach than others.  Please join us on November 11th to learn what these organizations are doing to improve patient collections, and how your practice can get to similar results.

Jessica Sweeney-Platt is a lead with athenaResearch


Paul Levy 1This has been my week to discuss networks (Internet and electricity), but I would be remiss if I didn’t spend a few moments on the networks that are most likely to rob us of personal choice and increase costs: Health care networks.

Wait, didn’t President Obama promise us that the new health care law would preserve choice for us? Didn’t he promise us lower costs?  Well, in spite of much good that the law accomplished in terms of providing access to health insurance, these are two areas that have gone awry. For a variety of reasons–most of which have little to do with providing you with better care–the hospital world has grown more centralized. It’s done so to reduce competition and get better rates from insurance companies. It’s done so to create larger risk pools of patients under the “rate reform” that incorporates more bundled and capitated payments. It’s done so to keep you as a captive customer for your health care needs. It’s been aided and abetted by electronic health record companies that find a mutual advantage with their hospital colleagues in minimizing the ability of your EHR to be easily transferable to other health systems. As I’ve noted, we truly have created “business cost structures in search of revenue streams,” rather than a vibrantly competitive system focused on increasing quality and satisfaction and lowering costs.

Many people don’t even know they are part of a health care network until they discover its limitations. It might be that the insurance product they bought has different rates for in-network doctors and facilities from out-of-network doctors and facilities. It might be that their primary care physician subtly or not so subtly directs them to specialists in his or her network because they share in the financial reward of eliminating “leakage” to other systems. It might be that they discover that an MRI or other image taken in one health system cannot be transferred electronically to another, perhaps necessitating a second image and its accompanying cost.


Screen Shot 2015-11-07 at 12.59.11 PMWhat if policymakers, science reporters and even scientists can’t distinguish between weak and trustworthy research studies that underlie our health care decisions?

Many studies of healthcare treatments and policies do not prove cause-and-effect relationships because they suffer from faulty research designs. The result is a pattern of mistakes and corrections: early studies of new treatments tend to show dramatic positive health effects, which diminish or disappear as more rigorous studies are conducted.

Indeed, when experts on research evidence do systematic reviews of research studies they commonly exclude 50%-75% because they do not meet basic research design standards required to yield trustworthy conclusions.

In many such studies researchers try to statistically manipulate data to ‘adjust for’ irreconcilable differences between intervention and control groups. Yet it is these very differences that often create the reported, but invalid, effects of the treatments or policies that were studied.

In this accessible and graph-filled article published recently by the US Centers for Disease Control and Prevention, we describe five case examples of how some of the most common biases and flawed study designs impact research on important health policies and interventions, such as comparative effectiveness of medical treatments, cost-containment policies, and health information technology.


Every year, Alex Drane takes us on an incredible journey through the health issues we don’t talk about. But should. Topics that were covered included:


jk-wallDonald Trump has been screaming about premiums going up this year for Obamacare health insurance policies.

But he should see what happens when they go down.

That’s what has happened in Indiana, where average premiums for 2016 health coverage on the Obamacare exchange is 12.6 percent lower than in 2015.

Because of that figure, journalists have declared Indiana the big winner, since premiums are rising by 10.2 percent on average across the country.

They could not be more wrong.

That’s because falling premiums are causing the size of the Obamacare tax credits to fall even faster in Indiana. And since 87 percent of Indiana’s exchange buyers this year received a tax credit, smaller tax credits will make the out-of-pocket cost far higher for those Hoosiers.

How much more? According to my analysis of insurer’s filing with the Indiana Department of Insurance, 30 percent, 60 percent, 90 percent and even 180 percent increases will be common for Hoosiers buying Silver plans for 2016, depending on their age and incomes.

Imagine what critics of Obamacare would be saying about those figures?

This topsy-turvy system is due to the convoluted system the Affordable Care Act set up to determine the size of tax credits in each state.


Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes


Devon HerrickA recent New York Times article profiled a pair of ultra-expensive pain medications designed to go easy on the stomach. Common pain relievers, like aspirin, ibuprofen and naproxen are prone to irritate the stomach if taken repeatedly throughout the day. A newer class of pain medication, called cox-2 inhibitors, are the preferred pain relievers for those who cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) on a long term basis. Celecoxib, the generic version of Celebrex, is now available at a cost of about $2 per tablet, but that can add up to about $700 to $1000 per year.

More than a decade ago researchers found that taking heartburn medications with common NSAIDs could mimic the benefits of the costly cox-2 inhibitors. However, the study found (at that time) combining heartburn medications and NSAIDS would not deliver any cost savings due to the high price of prescription heartburn treatments. A lot has changed in the years since the study. The costly proton pump inhibitors for heartburn are now available over the counter (OTC) for $0.31 cents to $0.60 cents apiece. The drugs mentioned in the Times article, Duexis and Vimovo, are based on the premise of combining NSAIDs with heartburn medications.

The catch? Each drug costs more than $1,500 for only a month’s supply. The cost per tablet is $17 and $25 respectively. Why so much? That’s a good question that doesn’t have a logical answer. Although nearly 90 percent of the drugs Americans take are inexpensive generics, a small segment – about 1 percent of all drugs prescribed – falls into a category known as “specialty drugs”.