With Amazon Purchase, it’s Time For Whole Foods to Bring Affordability Instead of Gentrification

With Amazon Purchase, it’s Time For Whole Foods to Bring Affordability Instead of Gentrification

On Friday, Amazon purchased upscale grocery and health food chain Whole Foods for $13.4 billion. Business outlets have praised the deal for both sides by noting that Amazon gains the brick-and-mortar presence that it has long sought while Whole Foods gains a major bump in stagnant stock prices. Squeezed by Costco, Target and Walmart’s increasing forays into the organic produce, Whole Foods was forced on the defensive in recent years, making shareholders unhappy.

Now, with the sale to Amazon, Whole Foods gains a second life as part of the world’s largest internet e-commerce company. Already, speculation has begun regarding how Amazon can leverage its technology to streamline Whole Foods’ operations and how Amazon can leverage the massive network of 460 stores in the US, Canada and UK to extend its relatively recent profitable streak.

But what do these obvious business benefits mean for American consumers?

While it will take time to know for sure, it’s probable that Amazon will add Whole Foods products to its AmazonFresh service, available to Amazon Prime members for an additional $14.99 a month. Competition in the American online grocery delivery service space has been unexpectedly fierce in recent years with companies such as FreshDirect and Instacart holding their own against Amazon and likely slowing AmazonFresh’s expansion into additional cities.

By adding Whole Foods products, Amazon will likely be able to entice more consumers into trying AmazonFresh. Both AmazonFresh and Whole Foods already target a traditionally overlapping customer base of affluent professionals so merging the ease-of-use of Amazon’s platform and logistics with Whole Foods robust brand penetration and food supply chain represents a real chance at achieving the retail ideal – a flexible grocery service with similar products both online and in-store.

But there’s one potential issue with such a strategy – pricing. In recent years, Whole Foods’ growth has stalled due to competition but also saturation among affluent consumers. Colloquially known as “Whole Paycheck”, it’s easy to see why when the grocery giant charges nearly double items like the popular New York bodega staple, a chopped cheese sandwich.

That is why it pivoted last year to attract lower-income consumers – to the delight of financial analysts. Evidence of this strategy can be seen most prominently at the corner of 125th Street and Lenox Avenue in Central Harlem where construction on a new Whole Foods is nearly complete in a traditionally underprivileged area.

But the problem with Whole Foods’ brick-and-mortar approach is that it relies too heavily on the forces of gentrification. Because Whole Foods is perceived to be a premium brand, housing prices around their locations tend to skyrocket. This Whole Foods effect means two things – (1) that Whole Foods never really expands its reach beyond residents who can afford the now inflated rents and (2) that Whole Foods never has the incentive to lower prices.

More brick-and-mortar locations and expanded delivery services will do little to help AmazonFresh and Whole Foods expand its customer base if its pricing isn’t brought back down to earth. With its purchase, Amazon has the opportunity to leverage efficiencies to bring prices down prices on groceries for both services.

Not only will this be good for the business by bringing in more customers, it’s good for America. Cities such as New Orleans, Chicago, Atlanta and Memphis have huge problems with food deserts – areas where communities have little to no access to healthy food such as vegetables, meats and dairy products. Approximately 2.3 million people live in low-income areas which are further than one mile from a supermarket with no access to a vehicle and such limited access to fresh food disproportionately affects African-Americans.

This prevalence of food deserts has a direct effect on Americans’ health. Living in a food desert forces people to fill in gaps in their diet with fast food. This spikes rates of obesity and diabetes in these communities – precisely the ones that can least afford to deal with the consequences given the current and potential state of American healthcare.

While not the entire answer to America’s distribution of healthy food, Amazon has the unique opportunity to provide more communities with access– either in-store or online. No retailer, even Walmart, has had such an opportunity to bring necessary goods directly to people before. While consumers shouldn’t begrudge Amazon for making a profit, this profit will also hopefully mean that more Americans get to enjoy readily available, and accessible, grocery options in their neighborhoods rather than just gentrification.

Jason Chung is currently senior researcher and attorney at NYU SPS Sports and Society, in New York. He tweets at @ChungSports

Don’t Underestimate Patients

Don’t Underestimate Patients

I was diagnosed with aggressive but localized prostate cancer at a major Dutch academic hospital. My parameters were PSA 29 or 31, Gleason sum 4 + 4, and stage T2c. Fortunately, there were no detectable distant metastases. The specialist drew a simple image of my urinary tract and told me I was excluded from brachytherapy, which I had never heard of before, because of the size of my prostate. I had to choose between external beam radiotherapy (EBRT) and radical prostatectomy (RP). How on Earth could I choose rationally while knowing so little about prostate cancer? However, I had studied maths and physics and could learn necessary medical science about my condition.

The Dutch healthcare system was privatized in 2006 by a special arrangement between the Health Ministry and the private insurers. This was the first healthcare privatisation in the European Union (EU). The effect of privatisation was, in my opinion, mixed. By the time I was diagnosed I already had much to distrust about the privatisation.

I sought a second opinion in Uppsala Sweden, where I had spent a lot of time as an academic visitor. Its Akademiska Sjukhuset (The Academic Hospital) has an excellent oncology division. I consulted two specialists.

They offered me a treatment that would solve the prostate size problem while being more effective than EBRT or RP alone. The treatment was by then world – class and in use in Norway and America. It is a trimodal technique involving EBRT, High Dose Rate Brachytherapy, androgen deprivation therapy (ADT) before radiotherapy (to make prostate smaller), and ADT during and three years after radiotherapy. The plan would be finalised later. I enjoyed the discussion so much that I decided to move permanently to Uppsala, and I started the treatment.

When I returned to the Netherlands to prepare to move, I ran into the doctor. Using my firm teacher’s voice I asked him why he had rejected me for brachytherapy. I did not tell him I had been in Uppsala. He kept referring to his Guideline but told me nothing else.

I found the guideline titled, ‘Guideline Prostate Carcinoma: Diagnostics And Treatment.’ The guideline made no allowance for my individual predicament.

For example, it stated that most studies of brachytherapy excluded Gleason sum > 6. ​Mine was 8.​ That is, according to this guideline the population for which brachytherapy was considered suitable or unsuitable did not include someone like me.

The guideline said nothing about using ADT to shrink the size of the prostate – again this is a  nuanced consideration about applying the guideline to individual cases. Why did the doctor not think nuance? Are we paying doctors for following guidelines or applying nuance?

The guideline said, “There is insufficient evidence that combining EBRT and brachytherapy for patients with localised cases yields better results [than either alone], at least for low and intermediate risk patients, while the morbidity [toxicity] seems to increase.”

My prostate cancer is high, not low or intermediate, risk. The guideline writers are worried about toxicity. I’m worried about death. How about asking me if I’m willing to take chances with “toxicity”? I did not want a prostatectomy but I did not want to be undertreated. Should I not have been asked how I felt about side – effects?

Why should doctors decide on a treatment plan without involving patients in discussions as to what they find an acceptable post treatment quality of life? This ​is ​done with prostate cancer issues like sexual potency and incontinence, which very many men know about. Why not others, e.g. radiation induced cystitis of bladder (me) and stricture? I fail to see any difference.

The age cut-off of the Dutch guideline for prostate cancer is 65. Yes, you heard right – 65! They were laughing about this in Uppsala.

My case raises a moral problem. Should doctors inform patients about where they can get the most effective treatments, at home or abroad? I was not, yet I did know about free international travel of EU citizens within the Union. Treaties exist concerning medical care of residents of EU country X in EU country Y. They are bilateral agreements. They ought to be used to help save lives.

State and private insurers should set up procedures to send patients abroad. Some are now, but I am convinced that this should be routine and unproblematic. Yet when I asked one of my Dutch doctors about care of prostate cancer in other countries a few days before I left, he replied, ‘we have our own ideas here.’ He did not know about my visit to Uppsala. He imposed his parochial ideas about quality of life on me. So the Dutch medical authorities chose probable death in The Netherlands over probable survival in Uppsala, albeit with reduced quality of life. How was this decided? By some local ethical and/or religious ideas? By cool financial analysis? By arrangements with insurers? Is following Guidelines more important than curing patients?

The choice was mine to make. I believe, were it not for my own initiative and inquiry, I’d have died prematurely from undertreatment.

About the author:

George Berger PhD is a philosopher of science. He lives in Uppsala Sweden. He’s a member of Disabled People Against Cuts, a large independent British group fighting benefit polices concerning ill and disabled people that have harmed many.

Don’t Let Weak Research Influence Policies with Life and Death Consequences

Don’t Let Weak Research Influence Policies with Life and Death Consequences

U.S. health care policies should be based on solid evidence, especially those policies with life-and-death consequences. All too often, though, they are not. Consider the recommendation by congressional advisors that the government should favor basic ambulances with only minimal equipment and less trained staff over advanced ambulances with more life-saving equipment and better trained staff. A poorly controlled study, however, claimed that patients were more likely to die during or after riding in the advanced ambulances than in the basic (but cheaper) ambulances.

Why would “basic” ambulances (with less life-saving equipment and with lesser trained staff) be better than the more advanced ambulances? They probably were not, and we’ll show how the data supporting the benefits of “basic” ambulances are unreliable, and often confuse cause and effect. Worse perhaps, the study offers yet another example of economic research devoid of context generating dubious national policy.

The Study    

Researchers at the University of Chicago and Harvard Medical School used insurance data to examine how well a large sample of Medicare beneficiaries fared after ambulance transport for out-of-hospital emergencies. They compared those sent in basic life support ambulances vs. people transported in advanced life support ambulances.

The results, published in the Annals of Internal Medicine, are of course counterintuitive: patients transported to the hospital in Advanced Life Support ambulances were more likely to die than those riding in the simpler, basic ambulances.

Questioning the Study’s Continuing Impact

The study is continuing to reverberate in research and policy circles. Almost a year after its publication, it was vigorously debated at the prestigious conference of the American College of Emergency Physicians (ACEP). Most emergency medicine leaders there questioned the veracity of the study and wondered about the absence of collaboration with emergency medicine specialists, who are trained in ambulance dispatch decisions that match the severely ill or dying patients with the most effective emergency transport. The emergency physicians also expressed worry that Medicare might reduce reimbursement for advanced ambulances on the basis of this unreliable study.

More troubling, in an recent interview , one national expert, Dr. Howard Mell, worried that the study represented a “ticking time bomb” (personal communication) given the new president’s emphasis on cuts to health care.

Most severely ill Medicare patients are currently transported by advanced life support ambulances, so it would be great if the cheaper ones were better. But there are several reasons why it’s premature for policymakers to act on this finding—yet another untrustworthy study with poor research methods, but much media hype.

The Evidence: Confusing Cause and Effect

First, the study seems to assume that severely ill patients are assigned to either an advanced or a basic ambulance by the flip of a coin. But this is not the case. Policy demands that advanced ambulances are sent to sicker patients, those further from the hospital and those more likely to die on route. It’s not random selection (like gold standard randomized trials); it’s often carefully considered selection.

Second, the study is almost devoid of data on how sick the patients were in each type of ambulance—exactly the sort of information emergency services often consider in assigning advanced life support ambulances in an effort to save critically ill patients.

This study wrongly creates the impression that advanced ambulances cause more deaths. In fact, they transport patients who are already more likely to die.

One large study shows that advanced ambulance teams are twice as likely as basic ambulances to pick up people with respiratory distress, serious breathing conditions, resulting in more deaths. In other words, people who are barely breathing are 100% more likely to get more advanced ambulances, making it appear that advanced ambulances “cause” more deaths when it is the opposite. People who can’t breathe and are more likely to die, are sent advanced ambulances in efforts to save their lives (the very definition of triage).

As can be seen in the above figure, patients transported in advanced ambulances were far more likely to be suffering life-threatening conditions. They were almost twice as likely to have supplemental oxygen, were a third more likely to be admitted to the hospital, and had 12 times the rate of electrocardiograph monitoring. Moreover, only patients in the advanced support ambulances had intravenous lines.

The graph above, likewise illustrates the more severe clinical conditions of patients transported in advanced ambulances. They were a fifth more likely to have very low blood pressure, and a third more likely to have very high blood pressure. They were almost twice as likely to have asthma or emphysema, and almost four times more likely to suffer from respiratory depression.

This is hardly the result of a flip of the coin. Remember also, all of these conditions occurred before hospitalization. All of the advanced ambulance patients were more likely to die from a large number of severe conditions occurring at the time they were picked up. It is virtually impossible to state that the health of patients transported by basic and advanced life support ambulances were the same.

What’s more, basic ambulances are more likely to pick up patients from skilled nursing facilities, where they are used as taxis to move healthy elderly to routine medical procedures—not usually near-death events.

Yet, another problem with the study is that it is correlational: research comparing patients during the same period of time. There is no calculation of any change in (or “effect” on) deaths. This type of design is so weak that the international scientific body that reviews tens of thousands of medical studies (Cochrane) immediately rejects it as evidence—even before examining any other weaknesses.

Not surprisingly, in an online forum, emergency medical technicians who attempt to resuscitate seriously ill patients reacted skeptically to the study’s findings.

One EMT responded, “We don’t send basic life support ambulance to a head-on car crash on a freeway.”

Another stated, “A basic unit probably won’t be activated for an elderly person who’s difficult to arouse, complaining of chest pain.”

And another: “… if you are receiving an advanced life support ambulance from the start, it is because the dispatch center infers your situation is severe enough to require ALS [an advanced life support] ambulance. So you are already more likely to experience poorer outcomes if you are being sent an ALS [the advanced life support] ambulance.”

Despite these limitations, the article’s authors proclaimed the salutary implications of their study, even calculating that the country would save many millions by abandoning more expensive advanced ambulances.

And, as usual, media outlets, including the Washington Post, trumpeted the findings under exaggerated headlines: “Need an ambulance? Why you might not want the more sophisticated version.”

Health policies with life-and-death consequences deserve strong evidence. At present, too much of the research in this field is weak. The National Institutes of Health have identified a disturbing phenomenon, the non-reproducibility of science. Unreliable studies confuse doctors, scientists, local politicians, and policymakers. They can also harm patients. Less expensive medical care is sometimes more effective, wise and more humane. But if the federal government overgeneralizes that message from unreliable studies on emergency care, we may see fewer patients survive their journeys to the hospital. More generally, we must not let weak research dictate policy that appears to be politically attractive but is foolish or harmful.

Stephen Soumerai is Professor of Population Medicine and teaches research methods at Harvard Medical School and the Harvard Pilgrim Health Care Institute.

Professor Ross Koppel teaches research methods and statistics in the Sociology department at the University of Pennsylvania and is a Senior Fellow at the Leonard Davis Institute (Wharton) of Health Economics. He is also affiliate professor of medicine at Penn’s medical school

Medical Associations Non-Pulsed by Trump’s Withdrawal From the Paris Accord

Medical Associations Non-Pulsed by Trump’s Withdrawal From the Paris Accord

By DAVID INTROCASO

Climate change, or changes in weather extremes, are having an increasingly harmful effect on human health. Last year, the 20th consecutive year in which the US experienced above average annual temperatures, saw increasing instances of heat related ailments and deaths and increases in related exacerbations of chronic, including cardiovascular, cerebrovascular, respiratory and mental health, conditions as well as the spread of climate change-related food pathogens and vector borne diseases, most recently Zika.

One study estimated that absent any adaptation to climate change or disruption we will see an increase of 2,000 to 10,000 deaths annually in over 200 US cities. Worldwide, the WHO estimates 800,000 die prematurely each year from urban air pollution stemming from burning coal, oil and gasoline. Not surprisingly, those disproportionately paying the climate penalty are children, pregnant women, the elderly, the disabled, minorities and the poor. Half of those killed by Hurricane Katrina (responsible for almost half of hurricane related deaths over the past 50 years) were over 75 and black adult mortality was upwards of four times higher than for whites. Half of Hurricane Sandy deaths were of those over 65.

When President Trump announced the US would withdraw from the 2015 Paris climate accord, signed by 195 nations, the news was met with widespread criticism. The president’s own Secretary of State, and former Exxon CEO, Rex Tillerson, opposed the decision.

Ironically, on May 11, Tillerson signed the Fairbanks Declaration that stressed the importance of reversing Arctic warming that is twice the rate of the global average and has caused, in part, the disappearance of 40 percent of summer Arctic ice. Twenty-five major US companies including Apple, GE, Goldman Sachs, Google, IBM, Microsoft along with energy giants National Grid, Pacific Gas and Electric, Peabody Energy and Shell, made known their opposition to withdrawal in full page New York Times and Wall Street Journal ads.

A 2015 study by Citigroup estimated climate change would cost the US at least $44 trillion in lost GDP over the next five decades.   Al Gore called the decision “reckless” and “indefensible.” Bill McKibben, the founder of 350.org., not surprisingly called it an “incredibly stupid decision,” and wrote the decision undercuts civilization’s chances of survival. Tesla and Space X CEO, Elon Musk, and others, resigned from several presidential councils. Among American voters nearly 70 per cent, including a majority in all 50 states, support the Paris accord.

Because there has always been a clear link between climate, weather and health, one would think the professional medical community would have led the chorus of condemnation. It has not. If you search the American Medical Association’s website, the AMA has had nothing to say about the president withdrawing from the Paris accord. The American Hospital Association (AHA) and the Federation of American Hospitals (FAH) websites also make no mention of Trump’s decision. The same is true for the American College of Physicians (ACP), the American Academy of Pediatrics (AAP), the American Geriatric Society (AGS), the American Diabetes Association (ADA), the American Heart Association (AHA), the American Lung Association (ALA) as well as, for example, the American Association for People With Disabilities (AAPD), the National Association of Medicaid Directors (NAMD), the Association of Health Plans (AHIP), and numerous other related organizations. It’s worth noting as well, if these organizations received their health-related news entirely from health policy-dedicated media they would be unaware of the president’s decision. Inside Health Policy, for example, has not written a single related article in the week following the White House’s decision.

The non-response by the nation’s leading medical trade and professional associations is sadly not surprising. They were equally indifferent when the president on March 28 signed an Executive Order (EO) that the White House press shop stated, “stops Obama’s war on fossil fuels.” Among other things, the EO allows the EPA to “review” President Obama’s “Clean Power Plan” initiative aimed at reducing carbon pollution or greenhouse gasses from coal plants by 32 percent of 2005 levels by 2030. (Carbon dioxide from fossil fuel use accounts for nearly 60 percent of greenhouse gasses.) The EO lifts a 14-month moratorium on new coal leases on federal lands and it eliminates guidance that climate considerations be factored into environmental reviews under the National Environmental Policy Act (NEPA). The EO is particularly disturbing when you realize the fossil fuel industry already has five times more carbon resources in its reserves than most believe is safe to burn. Last April when the Obama administration released a 400-page report, that included 150 pages of references, on the “impacts of climate change on human health,” a report drafted over three years by scientists at the EPA, NASA, NOAA, DHHS, DoD, the USDA and others, again, the AMA, the AHA and others had nothing to say.

The organization that has been vocal in addressing climate change, the outlier, is the American Public Health Association (APHA). It’s Executive Director, Georges Benjamin, immediately condemned Trump’s June 1 decision stating it “has disastrous consequences for human health.” When the CDC abruptly canceled a three-day climate and health meeting this past winter, the APHA along with others, none of whom were medical associations, stepped up and sponsored an abbreviated, one-day meeting on February 16 at the Carter Center in Atlanta. Among other programming, the APHA has since 2010 produced a climate change webinar series. The APHA, along with 40, moreover non-medical, organizations, declared 2017 as “the year of climate change and health,” in an effort to increase climate change awareness and mobilize action to protect public health.

The APHA has also partnered with 10 other medical societies, including three named above, i.e., the AAP, ACP and AGA, to recently form the Medical Society Consortium on Climate and Health. The consortium, publicly launched three months ago, did issue a press release in response to the president’s June 1 decision. It stated tepidly withdrawing from the Paris accord is “the wrong choice that puts Americans at unnecessary risk.” (To it’s credit the ACP released last year a “climate change and health” position paper that stated, albeit halfheartedly, “physicians . . . are encouraged to advocate for climate change adaptation and mitigation policies and communicate about the health co-benefits of addressing climate change.”)   The consortium pledges to advocate for energy efficiency and the transition to clean, renewable energy sources. Since the health sector is the largest energy consumer after the food industry, there is ample opportunity for the industry to go green. This is the mission of the Health Care Climate Council. One member, Kaiser Permanente, stated last year the organization will be carbon neutral by 2020 and has predicted by 2025 it will be carbon net positive. Another member, Gunderson Lutheran, has instead chosen to pursue a renewable energy strategy. Its largest alternative energy effort is a biomass boiler. However, burning biological materials for energy can emit as much or more pollutants as burning coal.

The US, after China, is the second largest greenhouse gas polluter, emitting over 6,600 million metric tons of green house gasses in 2015. Historically, the US is responsible for 27 percent of global CO2 emissions. We treat the atmosphere, the thin blue band that surrounds the planet, as an open sewer. That it appears we’ll continue to do so, and perhaps embolden others to do the same, is on balance not the concern of medical community. The greatest existential threat to our survival, our children and their children and the medical community is unwilling to raise its voice.

Today’s temperature in DC is 94 degrees, or 11 degrees above normal.

Being Human

Being Human

This is the most difficult blog post I’ve ever had to write. Almost 3 months ago, my sister passed away unexpectedly. It’s too painful to talk about the details. We were extremely close and because of that the loss is even harder to cope with.

The story I want to tell you today is about what’s happened since that day and the impact it’s had on how I view the world. In my work, I spend considerable amounts of time with all sorts of technology, trying to understand what all these advances mean for our health. Looking back, from the start of this year, I’d been feeling increasingly concerned by the growing chorus of voices telling us that technology is the answer for every problem, when it comes to our health. Many of us have been conditioned to believe them. The narrative has been so intoxicating for some.

Ever since this tragedy, it’s not an app, or a sensor or data that I turned to. I have been craving authentic human connections. As I have tried to make sense of life and death, I have wanted to be able to relate to family and friends by making eye contact, giving and receiving hugs and simply just being present in the same room as them. The ‘care robot’ that had arrived from China this year as part of my research into whether robots can keep us company, remains switched off in its box. Amazon’s Echo, the smart assistant with a voice interface that I’d also been testing a lot also sits unused in my home. I used it most frequently to turn the lights on and off, but now I prefer walking over to the light switch and the tactile sensation of pressing the switch with my finger. One day last week, I was feeling sad, and didn’t feel like leaving the house, so I decided to try putting on my Virtual Reality (VR) headset, to join a virtual social space. I joined a virtual computer generated room where it was sunny and in someone’s back yard for a BBQ, I could see their avatars, and I chatted to them for about 15 minutes. After I took off the headset, I felt worse.

There have also been times I have craved solitude, and walking in the park at sunrise on a daily basis has been very therapeutic.

Increasingly, some want machines to become human, and humans to become machines. My loss has caused me to question these viewpoints. In particular, the bizarre notion that we are simply hardware and software that can be reconfigured to cure death. Recently, I heard one entrepreneur believe that with digital technology, we’ll be able to get rid of mental illness in a few years. Others I’ve met believe we are holding back the march of progress by wanting to retain the human touch in healthcare. Humans in healthcare are an expensive resource, make mistakes and resist change. So, is the answer just to bypass them? Have we truly taken the time to connect with them and understand their hopes and dreams? The stories, promises and visions being shared in Digital Health are often just fantasy, with some storytellers (also known as rock stars) heavily influenced by Silicon Valley’s view of the future. We have all been influenced on some level. Hope is useful, hype is not.

We are conditioned to hero worship entrepreneurs and to believe that the future the technology titans are creating, is the best possible future for all of us. Grand challenges and moonshots compete for our attention and yet far too often we ignore the ordinary, mundane and boring challenges right here in front of us.

I’ve witnessed the discomfort many have had when offering me their condolences. I had no idea so many of us have grown up trained not to talk about death and healthy ways of coping with grief. When it comes to Digital Health, I’ve only ever come across one conference where death and other seldom discussed topics were on the agenda, Health 2.0 with their “unmentionables” panel. I’ve never really reflected upon that until now.

Some of us turn to the healthcare system when we are bereaved, I chose not to. Health isn’t something that can only be improved within the four walls of a hospital. I don’t see bereavement as a medical problem. I’m not sure what a medical doctor can do in a 10 minute consultation, nor have I paid much attention to the pathways and processes that scientists ascribe to the journey of grief. I simply do my best to respond to the need in front of me and to honour my feelings, no matter how painful those feelings are. I know I don’t want to end up like Prince Harry who recently admitted he had bottled up the grief for 20 years after the death of his mother, Princess Diana, and that suppressing the grief took him to the point of a breakdown. The sheer maelstrom of emotions I’ve experienced these last few months makes me wonder even more, why does society view mental health as a lower priority than physical health? As I’ve been grieving, there are moments when I felt lonely. I heard about an organisation that wants to reframe loneliness as a medical condition. Is this the pinnacle of human progress, that we need medical doctors (who are an expensive resource) to treat loneliness? What does it say about our ability to show compassion for each other in our daily lives?

Being vulnerable, especially in front of others, is wrongly associated with weakness. Many organisations still struggle to foster a culture where people can truly speak from the heart with courage. That makes me sad, especially at this point. Life is so short yet we are frequently afraid to have candid conversations, not just with others but with ourselves. We don’t need to live our lives paralysed by fear. What changes would we see in the health of our nation if we dared to have authentic conversations? Are we equipped to ask the right questions?

As I transition back to the world of work, I’m very much reminded of what’s important and who is important. The fragility of life is unnerving. I’m so conscious of my own mortality, and so petrified of death, it’s prompted me to make choices about how I live, work and play. One of the most supportive things someone has said to me after my loss was “Be kind to yourself.” Compassion for one’s self is hard. Given that technology is inevitably going to play a larger role in our health, how do we have more compassionate care? I’m horrified when doctors & nurses tell me their medical training took all the compassion out of them or when young doctors tell me how they are bullied by more senior doctors. Is this really the best we can do?

I haven’t looked at the news for a few months and immersing myself in Digital Health news again makes me pause. The chatter about Artificial Intelligence (AI), where commentaries are at either end of the spectrum, almost entirely dystopian or almost entirely utopian, with few offering balanced perspectives. These machines will either end up putting us out of work and ruling our lives or they will be our faithful servants, eliminating every problem and leading us to perfect healthcare. For example, I have a new toothbrush that says it uses AI, and it’s now telling me to go to bed earlier because it noticed I brush my teeth late at night. My car, a Toyota Prius, which is primarily designed for fuel efficiency scores my acceleration, braking and cruising constantly as I’m driving. Where should my attention rest as I drive, on the road ahead or on the dashboard, anxious to achieve the highest score possible? Is there where our destiny lies? Is it wise to blindly embark upon a quest for optimum health powered by sensors, data & algorithms nudging us all day and all night until we achieve and maintain the perfect health score?

As more of healthcare moves online, reducing costs and improving efficiency, who wins and who loses? Recently, my father (who is in his 80s) called the council as he needed to pay a bill. Previously, he was able to pay with his debit card over the phone. Now they told him it’s all changed, and he has to do it online. When he asked them what happens if someone isn’t online, he was told to visit the library where someone can do it online with you. He was rather angry at this change. I can now see his perspective, and why this has made him angry. I suspect he’s not the only one. He is online, but there are moments when he wants to interact with human beings, not machines. In stores, I always used to use the self service checkouts when paying for my goods, because it was faster. Ever since my loss, I’ve chosen to use the checkouts with human operators, even if it is slower. Earlier this year, my mother (in her 70s) got a form to apply for online access to her medical records. She still hasn’t filled in it, she personally doesn’t see the point. In Digital Health conversations, statements are sometimes made that are deemed to be universal truths. Every patient wants access to their records, or that every patient wants to analyse their own health data. I believe it’s excellent that patients have the chance of access, but let’s not assume they all want access.

Diversity & Inclusion is still little more than a buzzword for many organisations. When it comes to patients and their advocates, we still have work to do. I admire the amazing work that patients have done to get us this far, but when I go to conferences in Europe and North America, the patients on stage are often drawn from a narrow section of society. That’s assuming the organisers actually invited patients to speak on stage, as most still curate agendas which put the interests of sponsors and partners above the interests of patients and their families. We’re not going to do the right thing if we only listen to the loudest voices. How do we create the space needed so that even the quietest voices can be heard? We probably don’t even remember what those voices sound like, as we’ve been too busy listening to the sound of our own voice, or the voices of those that constantly agree with us.

When it comes to the future, I still believe emerging technologies have a vital role to play in our health, but we have to be mindful in how we design, build and deploy these tools. It’s critical we think for ourselves, to remember what and who are important to us. I remember that when eating meals with my sister, I’d pick up my phone after each new notification of a retweet or a new email. I can’t get those moments back now, but I aim to be present when having conversations with people now, to maintain eye contact and to truly listen, not just with my ears, and my mind, but also with my heart. If life is simply a series of moments, let’s make each moment matter. We jump at the chance of changing the world, but it takes far more courage to change ourselves. The power of human connection, compassion and conversation to help me heal during my grief has been a wake up call for me. Together, let’s do our best to preserve, cherish and honour the unique abilities that we as humans bring to humanity.

Thank You for listening to my story.

 

Government Regulation, Lawyers and the Opioid Crisis

Government Regulation, Lawyers and the Opioid Crisis

A short letter to a medical journal nearly 40 years ago may have been the nudge that set the opioid crisis in motion. A letter to the New England Journal of Medicine asserted addiction to prescription opioids was rare, claiming only four addictions were documented out of thousands patients who were prescribed powerful opioid pain pills in a hospital setting. The article has been cited hundreds of times in the years since. Doctors and drug makers may have relied on the letter as evidence that it was safe to prescribed opioids to more patients with chronic pain in settings far removed from carefully supervised hospitals.

Nearly 40 years later it has become clear that opioids can be dangerous in the wrong hands. There is also significant risk of diversion to the illicit market. After states began closing down so-called “pill mills,” prescription opioids became less available. To fill the void, heroin and fentanyl began flooding the U.S. to take the place of the once plentiful prescription opioids. Whole regions of the country have been hard hit by prescription drug abuse. Worse yet: other diseases tend to accompany IV drug abuse, including hepatitis C and HIV.

I’m reminded of a sequence of events that occurred about a dozen years ago. In late 2004 there was another pain reliever crisis. Pain relievers from a class of selective cyclooxygenase-2 inhibitors known as COX-2 Inhibitors, were suspected of harming patients by boosting the risk of premature death.

Vioxx and Bextra were both anti-inflammatory drugs once used to treat arthritis and acute pain. Vioxx was withdrawn from the market in 2004 due to safety concerns when prescribed for long-term use or in high doses. Bextra — another COX-2 inhibitor — was withdrawn from the market in 2005 due to some claimed side-effects that included an elevated risk of heart attack and stroke.

Over the course of a multi-year study that followed nearly 2,600 people, 45 of the patients taking Vioxx experienced heart attacks or strokes, compared to 25 people taking a placebo. The number of people in each group who actually died was five. Even though the death rate was equal, Merck removed Vioxx from the market — probably to reduce its liability. The makers of both Vioxx and Bextra paid out huge sums to settle lawsuits for people who died while taking the drugs.

These two drugs were popular because they did not irritate the stomach like other non-steroidal anti-inflammatory drugs (NSAIDs). Another reason people paid more for Vioxx (10 to 15 times more) than less-expensive pain relievers was because they caused less post-operative bleeding and protected the stomach against ulcers cheaper medications often cause. An estimated 16,500 patients who die annually of bleeding ulcers.

The millions of people worldwide who benefitted from access to Vioxx and Bextra are the real losers in withdrawal of the once popular prescription pain relievers. Of course, it’s easier to count those few people whom statistics suggest may have died in greater numbers than expected, even if only from natural causes, than to count those whose lives might have been extended by access to drugs taken off the market. The latter have no right to sue. The family members of thousands of deaths likely caused by older pain relievers can hardly be expected to attribute the deaths of their loved ones to a drug they couldn’t take. Yet under current law, those who die of a heart attack while taking a drug have every right to sue — even if the drug did them far more good than harm. They also have a right to sue even if the death of a family member cannot be proven to have been caused by the drug itself. The less effective, less expensive generic and over-the-counter pain relievers are poor targets for lawsuits.

More than 100 million people took these drugs before they were removed from the market. The use of COX-2 pain relievers also precludes taking aspirin daily to prevent heart attacks. Maybe that explains the slightly elevated risk of heart attacks and strokes from these drugs.

How many of the people in chronic pain who became addicted to opioids could have safely taken Vioxx or Bextra? We will never know. The ones who suffer the consequences are the patients, and they should be allowed to decide whether drugs are worth the risk, rather than having the decision made for them by a risk-averse FDA and other people’s lawyers. There is little reason to deny patients access to drugs like Bextra and Vioxx if they know the risks and are willing to accept them.

Devon Herrick, PhD is a health economist and senior fellow with the National Center for Policy Analysis.

A Not Very Good Proposal to Reduce Emergency Room Visits

A Not Very Good Proposal to Reduce Emergency Room Visits

A recent article posits that an Anthem company, Blue Cross and Blue Shield of Georgia (BCBSGA), is poised to “punish” its members for “unnecessary” emergency room (ER) visits by charging subscribers the entire bill for unnecessary ER visits.  This is a variation on a theme which has been playing out in virtually every state and every insurer:  how do we reduce the number of unnecessary emergency room visits? 

Of course, expecting a lay person to be able to parse out what is medically necessary for ER care and what is not is probably expecting too much.  Example:  I’m playing softball, slide into third base (at my advanced age), and jam my leg.  I’m not sure if it is a bruise, sprain, tear, or a break.  But it hurts like hell.  It’s 7:30 PM on a Tuesday.  What are my options?

Option A:  I could limp home, medicate with ibuprofen and a few beers, and hope it gets better.  When it does not, or next morning when I awake and am unable to ambulate out of my bed, what do I do then?  But of course, the pain might subside over a few days also.  My mom’s healthcare advice of wait and see might work.

Option B:  Call my primary care physician (PCP), who is closed for the day with a message that “if this is a medical emergency, dial 911.”  That’s helpful.

Option C:  Seek a free standing urgi-center and go there.  They likely will order x-rays, etc.  Is BCBSGA saying you can’t go there?  Unclear.

A spokesperson for BCBSGA stated:

…the policy wouldn’t apply when the patient is 14 or younger, an urgent care clinic isn’t located within 15 miles, or the visit occurs on a Sunday or holiday. She said it’s aimed at manifestly minor ailments — “If you had cold symptoms; if you have a sore throat. Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion.

The policy uses the “prudent layperson” standard, namely, what an average person would consider an emergency, not on the ultimate diagnosis reached by doctors after examinations and tests at the ER.

I understand what BCBSGA is trying to do.  We don’t want people using ERs as their PCP.  And it might be one thing to put a $75 or $100 copay on an “unnecessary” ER visit.  But to saddle the subscriber with the entire bill?

Were I to think that I might be saddled with the entirety of an ER visit bill (perhaps $2,000) if my view of “emergency” were not consistent with the prudent layperson test, as interpreted by the insurer’s staff who surely are not laypersons, I’d sure shy away from an ER visit.  Is that good?  Maybe and maybe not.  It will reduce ER visits; but given the “stitch in time” adage, on cases truly needing ER care who go without, the down-the-road bill may be much higher.

There are two possible alternatives here:

 

  • Spell out in more detail what will and will not suffice;
  • Get hospital ERs to triage care in a very different way.

 

Perhaps the ERs of the future have an intake specialist that directs patients in one of three directions:

 

  • Full ER;
  • Urgi-center (co located);
  • Send home with note to see PCP.

 

Are there liability concerns?  For sure.  But those abound in every scenario.  The best defense is to establish a community standard of ER care and use that is the guideline for triage.  That at least gives one some defense against malpractice claims, which by definition require proof of a violation of the accepted community standard of care.

In summary, I think the proposed course by BCBSGA is not appropriate.  We need to have professionals deciding what is medically necessary and what is not.  To that end, ERs must engage in true triaging with appropriate levels of care at appropriate costs.

 

 

Would ACOs Work if They Were Turned into HMOs?

Would ACOs Work if They Were Turned into HMOs?

CMS has now conducted three demonstrations of the “accountable care organization,” and all of them have failed. The Physician Group Practice (PGP) Demonstration, which ran from 2005 to 2010, raised Medicare costs by 1.2 percent. [1] The Pioneer ACO program, which ran from 2012 through 2016, cut Medicare spending by three- or four-tenths of a percent on average over its first four years. And the Medicare Shared Savings Program (MSSP), which began in 2012 and may lumber on indefinitely, has raised Medicare costs by two-tenths of a percent on average over its first four years.

It is way past time for CMS and health policy researchers to determine why all three ACO demos failed. In the first two installments in this three-part series I laid out one of the reasons: CMS’s method of assigning patients to ACOs guarantees ACOs must apply their magic to a rapidly changing pool of patients and doctors. In the first essay , I demonstrated that this method, which assigns patients first to doctors based on where they get the plurality of their primary care visits and then to ACOs if their doctors are in ACOs, guarantees high churn rates among doctors and patients, shunts sicker patients away from the ACOs, and assigns few ACO patients to each ACO doctor. In the second essay I reviewed the series of evidence-free decisions that led to CMS’s plurality-of-visits method. I noted that the first of these decisions was one Congress made: They instructed CMS to figure out how to assign patients to ACOs without making patients enroll in ACOs.

In this last installment I ask what if anything can be done to reduce the patient churn rate, and whether reducing the churn rate would do anything to improve the performance of ACOs. I’ll first review the argument some ACO advocates make that the churn rate could be greatly reduced if “attributees” were induced to stay within “their” ACO. We will see that there is little reason to believe that. Then I’ll go on to ask whether ACOs would work even if “attributees” were forced to enroll with an ACO, a requirement that would effectively define ACOs as HMOs. I’ll answer that question in the negative on the ground that the cost-control tactics available to ACOs, namely those that have long been available to HMOs and other insurance companies, have not worked.

Finally, I’ll discuss the only feasible option I see for salvaging something from the entire ACO/HMO experiment: Requiring that CMS and Congress abandon the fantasy that ACOs/HMOs can do something positive for entire “populations” and instead require them to provide defined services to patients with specific diagnoses.

I would like to apologize in advance for the frequent use of quote marks around words like “attributee” and “attestation.” But I insist on using them to warn readers that when we attempt to understand the conversation about ACOs we enter a strange world where words don’t mean what they seem to mean.

Back-door enrollment

When it became clear that the ACO would be enshrined in the Affordable Care Act, many observers asked whether ACOs weren’t merely warmed over HMOs. Proponents replied that HMOs were different from ACOs in several respects, the most important of which was that Americans would not have to enroll with ACOs and use only ACO doctors and hospitals. [2]

But it wasn’t long before ACO advocates began to complain that this distinction was making it impossible for ACOs to lower costs. Pioneer ACO managers voiced this complaint to L&M Policy, the author of the final evaluation of the Pioneer ACO program. “Representatives from many of the Pioneer ACOs noted that it was more difficult than initially anticipated to manage beneficiary utilization and patient visits outside of the ACO because beneficiaries did not face financial incentives to use ACO providers,” L&M reported. “Some ACOs reported frustration with translating existing care management programs to the ACO population without the benefit of traditional managed care tools (e.g., enrolled population, utilization management, prior authorization)….” (p. 70)

ACO proponents have responded to this lament with two related proposals: (1) CMS should ask “attributees” to “attest” that an ACO doctor is “their” doctor and, if they say yes, CMS should count them as ACO patients; and (2) ACO “attributees” should be given financial incentives to sign the letter and stay within the ACO network. As is always the case with managed care proposals, advocates have proposed these “reforms” without a hint of evidence that they’ll work or what they might cost.

You can readily see these two proposals together recommend enrollment without using the “enrollment” word. So why don’t proponents of these “reforms” just admit they want Medicare recipients to enroll in ACOs and suffer financially if they go outside the ACO network? I submit they know there was a hellacious HMO backlash in the latter half of the 1990s, triggered primarily by American hostility to limitations on choice of doctor, and that many Medicare recipients in FFS Medicare are there because they don’t want to enroll in a Medicare Advantage plan, and they’re hoping Medicare beneficiaries will be too dumb to notice that they’re being offered a bribe to enroll in an HMO dressed up as an ACO.

Avid ACO proponent and former CMS administrator Mark McClellan, for example, offered the enrollment-by-another-name proposal in a list of “reforms”  of the MSSP program he sent to CMS Administrator Marilyn Tavenner in February 2015. He proposed CMS should mail an “attestation” form to “attributees” that “attributees” could sign and thereby “positively identify their primary care provider … and thus declare their active participation in an ACO.” (p. 6) Got that? “Active participation” would be “declared.” What does “active participation” in something as vague as an ACO mean? Would it mean signers agree to stay within the ACO’s network? McClellan didn’t say. That was for Tavenner to figure out.

But McClellan hinted that that’s exactly what he meant when he described an additional proposal to expose “attributees” to financial incentives: “We also recommend that CMS consider additional incentives for patient participation in the ACOs, including waiving or reducing copays and deductibles for patients when they receive care from their primary care physician or other providers in the ACO.”

McClellan offered no evidence that his back-door enrollment proposal – one which would eliminate one of the few distinctions between ACOs and HMOs – would work. And he offered no estimate of what it would cost. [3] Obviously, contacting patients and urging them to sign “attestation” documents would cost money, and so would paying patients to stay within ACOs/HMOs.

Explaining Groupthink to Doctors

Let’s focus first on the “attestation” nostrum. Let’s set aside the cost issue for now, and ask the question that McClellan and other ACO advocates never address or address only with happy talk, namely: Even if CMS spends whatever it takes to contact every ACO “attributee” and urge them to sign a piece of paper that “declares their active participation” in an ACO, what good will that do? Remember, the message from CMS about the “attestation” form would be in addition to the notice CMS already sends out to Medicare beneficiaries indicating they have been assigned to an ACO.

Let me begin by reviewing evidence from the final Pioneer ACO evaluation on how poorly ACO doctors understand the vague “ACO” concept. Once you comprehend how confused the doctors are, you’ll shake your head and wonder how anyone could think patients will ever understand the flabby ACO concept. Remember, we’re discussing the crème-de-la-crème here – CMS selected the 32 hospital-clinic and clinic-clinic chains to participate in the Pioneer program because of their size and previous experience “managing care.” If doctors anywhere understand ACOs, you’d think it would be the doctors in the Pioneer ACOs.

Although ACO proponents claimed ACOs would be “run by doctors” and would therefore be kinder and gentler than HMOs [4], it turns out doctors not only didn’t run the Pioneer ACOs they had a poor understanding of what their ACOs were doing to and for them. According to L&M’s final evaluation of the Pioneer program, “The vast majority of providers participating in Pioneer ACOs were not directly part of the decision to participate, but rather were employed by or part of a medical group that joined the ACO.” (p. 23) The evaluation went on to say, “Survey results indicated that only 2 percent of Pioneer physicians had served on the ACO board of directors and only 9 percent had served on an ACO committee. Even for those reporting such involvement, only half of Pioneer physicians said they were satisfied with their participation….” (p. 43)

Because the vast majority of doctors weren’t involved in the decision to join an ACO, and because the ACO is so poorly defined [5], doctors had little comprehension of what their ACOs were doing. “In several respects, physicians were not particularly knowledgeable about the ACO,” reported L&M. “When asked if they knew which of their patients were aligned with the Medicare ACO, just over a third of Pioneer physicians reported knowing which beneficiaries were aligned and a similar proportion reported not knowing their aligned beneficiaries at all. When asked about the elements of their compensation, almost half of physicians participating in the Pioneer model reported not knowing whether they were eligible to receive shared savings from the ACO….” (p. 43)

Given their incomprehension of the ACO thing, Pioneer physicians understandably were unable to generate the evidence-free hype about ACOs that ACO advocates can generate in their sleep. For L&M and ACO management, physician confusion about ACOs reflected a defect in physicians, not in the wonderful ACO project. “Nearly all Pioneer ACOs reported interest in improving physician engagement,” L&M reported, “with many reporting frustrations in the perceived lack of engagement by physicians with the ACO.” (p. 41)

But maybe, just maybe, the problem wasn’t with the knuckle-dragging doctors. Maybe it was that ACOs were either doing so little that most doctors couldn’t detect anything that might be called an ACO intervention, or that doctors did perceive some ACO interventions but viewed them as not helpful. L&M did report that 70 percent of ACO physicians thought they were already practicing in a manner consistent with the goals trumpeted by ACO advocates, and for that reason, “they may have believed that they did not need the structure or strategies provided by the ACO to adapt to new approaches to care delivery.” (p. 42)

The one feature of ACOs the great majority of doctors understood clearly was that ACOs impose more paperwork on doctors. “Approximately three-quarters of Pioneer physicians indicated that participation had required them to increase time spent on administrative, documentation, and reporting tasks…, ” said L&M. (p. 45)

Explaining Groupthink to the Unwashed Masses

If doctors who have been roped into ACOs don’t understand ACOs, is there any hope that their patients will sign “attestations” with anything resembling informed consent? Informed consent, it should go without saying, will be necessary if “attestation” is to have any chance of influencing patient behavior.

In fact, the Pioneer program did make use of “attestations” (but not financial incentives). According to a December 2011 CMS press release, “beneficiaries may affirmatively attest that their primary provider is in a Pioneer ACO, and can then be aligned with the ACO and benefit from the enhanced care coordination that it offers.” (p. 2) Obviously “attestation” didn’t work. Why not? Because the ACO is so poorly defined ordinary mortals can’t understand it.

L&M discovered that “attributees” in Pioneer ACOs didn’t have the faintest idea what an ACO is. L&M concluded, “Despite the annual notification letter and Pioneer ACOs’ efforts to engage beneficiaries, in small group discussions with beneficiaries … we learned that beneficiaries were generally unaware of the ACO organization and the term ‘ACO.’ In the few cases where the beneficiaries reported hearing the term ACO, they were not able to describe what an ACO is….” (p. 51) Although L&M did a great job measuring and reporting high churn rates among Pioneer doctors and “attributees,” they made no attempt to ask why “attestation” didn’t work. [6]

If you were in charge of contacting “attributees” and urging them to sign ACO “attestations,” what would you say? Don’t bother asking ACO advocates like McClellan for help. Here’s all McClellan had to say on this topic in his letter to Tavenner: “CMS should also support better patient education around the goals and features of Medicare ACOs, and how patients can work with their providers to improve care.” (p. 6)

Would ACOs Work if “Attributees” Had to Enroll in Them?

For the sake of argument, let’s pretend that CMS could explain ACOs to Medicare recipients, that all recipients assigned to ACOs could be persuaded to “attest,” and that this back-door enrollment requirement reduced “attributee” churn. Would CMS’s ACO programs finally start cutting Medicare spending? (Note that I’m not asking whether the costs ACOs incur to do whatever ACOs do would exceed any savings for Medicare. I’m only asking whether Medicare costs might drop.)

To answer that question, we would need to know what interventions ACOs would apply to “their” patients. Sad to say, a decade after the phrase “accountable care organization” was invented, we don’t know what ACOs do. Again, that’s because the definition of the ACO is so vacuous. As L&M put it in their first evaluation  of the Pioneer program, “The ACO ‘treatment’ under investigation is not a prescribed set of activities or interventions. Rather, it is a financial arrangement….” Is it possible to be any more abstract? Have you ever seen a more useless definition of anything?

Even the managers of the Pioneer ACOs were in the dark. “The vast majority of Pioneer ACOs entered the model with care management experience,” L&M stated in the final evaluation. “However, there remained a decided lack of consensus on what makes care management effective.… Even through the third year of the [demonstration], Pioneer ACOs continued to report using trial and error to make incremental changes and improvements to their care management programs.” (p. 48)

So how does one rationally inquire why ACOs are failing when no one knows what they’re supposed to be doing? Lawton Burns and Mark Pauly, economists at Wharton, addressed this question in a 2012 paper in Health Affairs. They politely characterized the flabbiness of the ACO concept as a “lack of consensus … over what the new entities should do, or stop doing, to reduce spending and how they should control out-of-network utilization.” Then they attempted to do that which ACO advocates should have done before promulgating the ACO “arrangement”: They listed the tools or interventions available to ACOs and reviewed the evidence on each one.

Burns and Pauly made the reasonable assumption that ACOs had no choice but to use the same managed-care tools that HMOs and kindred insurers were using, such as utilization review, pay-for-performance, health information technology, and the ever-popular “care coordination.” After reviewing the literature on these tools they concluded, “The evidence … suggests that components of accountable care organizations have limited and uncertain impact, especially on cost savings, and thus provide little support for the [claim that] better care coordination will improve quality at any given cost, and … the organizations will lower Medicare’s rate of spending growth.” (p. 2412) [7]

If the tools available to ACOs can’t lower costs, then reducing churn among ACO “attributees” by forcing or bribing them to enroll in ACOs will do little to improve the ACOs’ ability to cut costs. To put it another way, the high rate of turnover among ACO “attributees” is not the most significant reason ACOs are failing. They’re failing because the cost-containment tools available to them are so ineffective. These same tools didn’t work for HMOs and other insurance companies, and of course enrollment is required for insurance.

Salvaging Something From the ACO Experiment

The taxpayer has now financed three ACO demonstrations – the PGP, Pioneer, and MSSP demos. [8] All of them have failed to cut Medicare spending; all of them are raising costs if ACO intervention costs are taken into account. The purpose of demonstrations is to learn something. Sad to say, we have learned nothing from the ACO demos. No one – not CMS, not MedPAC, not ACO buffs – can explain the chronic failure of Medicare ACOs (see my discussion of MedPAC’s bafflement here ).

The ACO demonstrations will not have been a total waste of money if CMS can determine whether any ACOs did anything that improved the quality of care of specific patients. It is possible that some of the managed care tools ACOs are expected to use would work (that is, they would at least improve quality and might lower costs as well) if they were applied to subsets of the chronically ill. It’s clear those tools are never going to work if they are applied to entire “populations.” Managed care proponents must stop thinking in terms of structures (ACOs, HMOs, “integrated systems,” “medical homes”) that apply managed care magic to entire populations, and start thinking in terms of specific services delivered to subsets of the chronically ill.

[1] According to the final report on the Physician Group Practice Demonstration, “[T]he demonstration saved Medicare .3 percent of the claims amounts, while performance payments were 1.5 percent of the claims amounts” over the five years the demo ran, for a net loss of 1.2 percent. (p. 64)

[2] Austin Frakt and other ACO proponents claimed that another difference between ACOs and HMOs is that ACOs bear less risk than HMOs. They argued that ACOs would not bear total insurance risk but would instead be subjected to a lower level of risk-sharing called “shared savings,” and this would give doctors and their ACO managers less incentive to deny necessary services to patients. But other ACO advocates claimed just the opposite – that ACOs were expected to move gradually from the limited risk of shared savings contracts to full blown insurance risk delivered via capitation aka premium payments. For, example, the final evaluation of the Pioneer ACO program stated, “CMS intended the model to allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model.” (p. xii)

Some ACO advocates also sought to distinguish ACOs from HMOs with the claim that ACOs would be more “accountable” than HMOs ever were because the spread of electronic medical records and alleged advancements in quality measurement since the “HMO backlash” of the 1990s would make it easier for unidentified third parties to monitor the quality of ACO medical care (see, for example, CMS’s brave promise to “routinely analyze data surrounding utilization of services” at p. 2 of this 2011 press release ). Thus, even if the shifting of some but not all insurance risk to ACOs induced ACOs to short-change their patients, all-seeing monitors would detect this behavior and correct it. Here are other examples of experts who claimed ACOs were not HMOs in drag: Ezekiel Emanuel in a 2012 comment  for the New York Times blog; two experts quoted in a 2015 article  by Kaiser Health News.

[3] Here is the totality of the “evidence” McClellan offered CMS administrator Tavenner in his February 2015 letter to her in support of his proposal that CMS allow ACOs to try to induce “attributees” to “attest” to their loyalty to an ACO doctor: “Results regarding the extent to which patients choose to join an ACO and the potential long-term impact are not yet available, but private-sector programs have had promising results, and increased beneficiary engagement is a fundamental objective for Medicare.” (p. 6)

[4] Obama adviser and ACO advocate David Cutler claimed ACOs would not “dictate to doctors and patients what they are allowed to do and what they cannot” as HMOs did (see Austin Frakt’s New York Times comment in footnote 2).

[5] For a discussion of the flabby, aspirational definition of “ACO,” see my comment here

[6] The problem ACOs face in inducing “attributees” to give a hoot about “engaging” with “their” ACO may go beyond the inability of mortals to comprehend what “ACO” means. According to L&M, many Pioneer ACO managers believe the problem is resistance to HMO-like interference in the doctor-patient relationship. I quote from the final Pioneer evaluation: “Pioneer ACOs highlighted difficulties managing FFS beneficiaries; these ACOs often contrasted ACO-aligned beneficiaries to beneficiaries in MA [Medicare Advantage] plans. … Some Pioneer ACOs asserted that beneficiaries often choose traditional Medicare FFS specifically because they do not want provider network limitations, and these patients may have construed efforts to engage them in the ACO as an effort to limit provider choice.” (p. 51)

[7] The conclusion by Burns and Pauly that none of the managed care tools work is consistent with other analyses using different methodologies. I reported in a literature review  published in Health Affairs in 2000 that insurance companies that use managed care tactics are not cutting costs. In a 2015 paper financed by the leading lights of the American health care establishment, Lawton Burns and Jeff Greenfield examined the evidence for “Kaiser-like entities,” aka “integrated delivery systems.” In a blog comment  about that paper, the authors stated, “We reviewed more than 30 years of academic literature on vertical integration and diversification in healthcare, and found virtually no measurable benefits – either to society or to the sponsoring healthcare enterprises themselves – of putting health insurance, hospitals and physician services under the same structure.”

[8] Strictly speaking, only the PGP and Pioneer experiments were “demonstrations.” The MSSP program was authorized by the Affordable Care Act and is a permanent program as long as the ACA remains law.

How Amazon Can Position Itself as the Pharmacy of the Future

How Amazon Can Position Itself as the Pharmacy of the Future

We know Amazon has a knack for disruption—over the years it has upended countless brick and mortar bookstores and other major players in the retail industry. The e-commerce behemoth may be at it again, making headlines for its interest in breaking into the pharmacy market in the United States. But delivery of prescription medications to the home already exists for patients with chronic and even acute conditions, while patient portals already give patients online access to payments and prescription refills. So how might we expect Amazon to set itself apart from the competition and grow in the pharmacy space? If it stays true to the tenets of Disruptive Innovation, expect it to further expand its capabilities around healthcare in the home—just as it has kept book, grocery, and other retail shoppers at home over the years.

The principles of disruption

The Theory of Disruptive Innovation is widely acknowledged as a theory of competitive advantage brought forward by Clayton Christensen in his book The Innovator’s Dilemma. Its creation was in response to many well-run and successful companies faltering despite making, seemingly, all of the correct management decisions. After studying numerous cases Professor Christensen found that disruption stemmed from companies improving their offerings to an extent that they overshoot mainstream consumers’ demands for performance—often in pursuit of catering to their most demanding and profitable customers. Disruptive entrants capitalize upon this to reach less demanding and mainstream markets by bringing to market solutions that cost less and are more simple and convenient to use—often selling a product considered “inferior” in terms of traditional performance standards.

Amazon’s medication delivery program is not likely to be able to make an impact in the pharmacy industry on its own. Mail order pharmacies have been around for decades, and in many cases drug delivery may actually be less convenient than just picking up a prescription in person, as many pharmacies are co-located at the point of care. Amazon will instead have to find a way to reach less competitive markets, neglected by their existing competition, with its option of drug delivery. It can do this by hitching a ride with another disruptive technology that is already reaching previously neglected populations with convenient access to care.

Riding the coattails of telemedicine

Telemedicine (the use of telecommunications technology to evaluate, diagnose and/or treat patients in remote locations) holds promise for Amazon as an entrypoint into the pharmacy market, and as a vehicle to carry the company upmarket. Virtual visits have improved access to professional medical expertise in areas where the nearest doctor’s office may be over 40 minutes away, and in urban areas where the nearest appointment slot to see the doctor located down the road may be multiple days. For these reasons, along with the convenience of care at home, telemedicine is rapidly growing in use and is becoming more frequently turned to for acute and chronic care cases. In fact, Kaiser Permanente’s CEO Bernard J. Tyson recently revealed that, last year, over half of Kaiser’s patient visits were conducted via online portals, virtual visits, or the health system’s apps.

Amazon’s e-commerce platform can capitalize on the growth of telemedicine by finding ways to seamlessly integrate the process of ordering prescription drugs from its website into the virtual visit experience of major telemedicine vendors. By doing this, the common workaround of the physician having to find a pharmacy near the patient to send in the prescription can be overcome. Instead, the familiar Amazon checkout process can be used to approve the order sale and delivery of prescription medication directly to the patient. From the perspective of the sick patient, being allowed to opt-in to medication delivery prevents needing to leave the home to pick up the prescription, improving the patient experience for many illnesses.

Reach underserved markets with an innovative business model

Telemedicine is an attractive option for patients when they cannot see their provider in-person within a convenient timeframe. But, as the Theory of Disruptive Innovation would suggest, in order for patients to turn to telemedicine, they must still believe that virtual visit technology is “good and reliable enough” to meet their needs before they give in to the convenience. Right now, use of telemedicine technology is limited to only certain, routine and less demanding, patient care cases because of this performance-convenience tradeoff. As telemedicine technologies improve over time and become “good and reliable enough” for more complex and demanding patient cases, usage will increase beyond markets lacking adequate access to care and more patients will confidently opt for their convenience. Because of this, those pharmacies that are well equipped to integrate their online ordering process into the virtual visit processes of the major telemedicine vendors will hold an important advantage.

By integrating its medication delivery services into the virtual visit process of major telemedicine vendors, Amazon can first make its online pharmacy easily available in markets where patients lack convenient access to care or a pharmacy. In this way, Amazon can avoid direct competition with established pharmacy competitors who tend to concentrate in wealthy areas, and improve its odds for early success. Over time, as telemedicine capabilities improve and advance upmarket, Amazon’s medication delivery option will reach more patients, and become more and more attractive as the delivery speed of Amazon and affiliates improve.

Influencing care in the home

Healthcare is increasingly adopting new payment models that shift financial risk upon providers to manage the costs of patient care. This additional risk has compelled providers to find ways to improve medication and regimen compliance among patients. In many ways, Amazon is already building the capabilities that providers seek—to influence personal behavior and consumer habits outside the doctor’s office. Its new personal assistant technology Alexa, for example, may be able to remind patients to take their medication, send an order to refill a prescription, or assist in scheduling a telemedicine appointment all by voice command in the home (see Alexa diabetes challenge). These additional experiences could be included with an order from the online pharmacy, and hold potential to make monitoring and compliance easier for patients with chronic conditions. In this way, Amazon can keep patients healthier and providers happier, and improve the likelihood they turn to Amazon in the future.

Telemedicine has already made progress in reaching new and neglected markets with convenient care options. Amazon can stake its claim as the pharmacy of choice for providers and patients engaging in virtual healthcare at home, and grow alongside the booming technology that is disrupting in-person patient care as we speak. To do this, the e-commerce powerhouse will have to successfully integrate ordering and checkout from its pharmacy into as many telemedicine processes as possible, and continue its progress in influencing consumer behavior at home. If Amazon can accomplish this, it will be set to break into the pharmacy space in a big way, just as it has changed the face of numerous other industries.

Ryan Marling is a research associate at the Clayton Christensen Institute for Disruptive Innovation. 

HarvardX: Improving Global Health, Focusing on Quality & Safety

HarvardX: Improving Global Health, Focusing on Quality & Safety

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