Regarded

By NIRAN AL-AGBA, MD

According to recent Ohio statistics, 1.3 million people have limited or no access to primary care physicians. Based on the 2015 Ohio Primary Care Assessment, 60 of 88 Ohio counties have medically-underserved populations.  The Patient Access Expansion Act (HB 273), co-sponsored by Representative Theresa Gavarone (3rd District) and Representative Terry Johnson (90th District), specifically addresses healthcare access by prohibiting physicians from being required to comply with maintenance of certification (MOC) as a condition to obtain licensure, reimbursement for work, employment, or admitting privileges at a hospital or other facility. 

Recently, I spoke with Representative Gavarone on the critical importance of this legislation for Ohio.  Physician family members have grumbled about the expense of MOC compliance however, a practicing cardiologist better clarified the connection between MOC regulations and the growing physician shortage.  “He shared his frustrations at the time and money involved participating in a program that has absolutely no scientifically-proven benefit for patient outcomes,” said Representative Gavarone.  The cardiologist discussed numerous hours wasted preparing for an exam with little to no bearing on his day-to-day work serving his patients.

While the public may not be familiar with the harm of MOC regulations, many have experience searching for a new physician when their doctor retires earlier than anticipated.  “Patients are waiting months for appointments,” said Representative Gavarone.  “As physicians leave their practices through cutting back or early retirement, this translates to reduced access to care for everyday Ohio citizens,” she said.   Gavarone is touching on a vital issue facing practicing physicians across the country:  there are fewer incentives for compassionate, brilliant minds to enter the field of medicine.    

Oklahoma was the first state to enact Anti-MOC legislation and six more states (Georgia, Maryland, Missouri, North Carolina, Oklahoma, Tennessee and Texas) have passed laws prohibiting the use of MOC as a condition for obtaining medical licensure and hospital admitting privileges.  Doctors are being “boarded to death”.  To become licensed to practice medicine in the U.S., we must pass 4 exams, each lasting 16 hours in duration over 2 days.  The US Medical Licensing Exam (USMLE) has three parts:  USMLE Step 1 and 2 are taken during our second year and fourth years of medical school, and Step 3 is taken over a two-day “vacation” during internship year. 

After a 3-5 year residency program, we must pass a specialty-specific board exam, such as internal medicine, pediatrics, or surgery to become licensed.  While drowning in more than $100,000 in educational debt, the $1500 exam fee seemed exorbitant, yet passing the pediatric certification exam was only a one-time requirement. States already mandated completion of Continuing Medical Education (CME) hours annually for physician licensure, so why were additional requirements necessary?

The American Board of Medical Specialties (ABMS) eliminated “lifetime” certification to shore up their financial outlook; a modification having little to do with quality and much to do with rate of return.  Between 2003 and 2013, the ABMS member boards’ assets ballooned from $237 million to a staggering $635 million, an annual growth rate of 10.4%.  MOC is outrageously lucrative.  Almost 88% of their revenue came from certification fees. 

The testing environments to which physicians are subjected are abominable; those who are disabled, ill, pregnant, or nursing find their requests for accommodations in accordance with federal ADA guidelines denied, having no recourse for blatant discrimination.  MOC requirements violate our basic right-to-work, an intrusion deemed intolerable in other professions.

Groups lobbying heavily against anti-MOC legislation will likely be hospitals, insurance companies, and specialty groups, such as the American Society of Plastic Surgeons (ASPS) and Ohio Valley Society of Plastic Surgeons (OVSPS), who are out of touch with front line physicians.   Both organizations vehemently opposed a tax on elective (read: unnecessary) procedures projected to add $25 million to the state budget, calling it “discriminatory, economically damaging, and fiscally unsound.” They oppose HB 273 on the grounds that allowing board certification to “lapse” will prevent patients from receiving the “highest quality of care;” a statement that is altogether unproven, misleading, and deceitful. 

If you like your doctor, support HB273 –the Patient Access Expansion Act so you can keep them. The MOC program forces physicians to spend time away from our patients, clinics, and families for no demonstrable benefit.  Financial corruption touches every facet of MOC; the American Board of Medical Specialties has $701 million reasons to oppose this bill.  Representatives Gavarone and Johnson are David bravely battling Goliath.  Physicians and patients must help them fight for high-quality, affordable healthcare to be delivered by physicians free of futile testing regulations.   

Niran Al-Agba, MD is a pediatrician in Washington State.

By RICH DUSZAK, MD

When four physician certification boards founded the American Board of Medical Specialties (ABMS) in 1933, those forward thinking organizations—and their professional society sponsors—launched a national movement toward ever increasing physician accountability. Back then, quackery was rampant, so “board certification” meant a lot to patients. The ABMS has since grown to 24 member boards, all ostensibly dedicated to serving “the public and the medical profession by improving the quality of health care through setting professional standards for lifetime certification.”

Because information and technology now advance so rapidly, those one-time lifetime certificates from years ago may no longer be enough. A doctor who passed a test in 1990 isn’t necessarily competent today. The boards have thus changed their approach to certification; for newly minted physicians, time-limited (e.g., 10 year) endorsements now replace the lifetime ones granted to their predecessors. Initially contingent on additional examinations each certification cycle, these newer time-limited endorsements now additionally require ongoing participation in Maintenance of Certification (MOC®) programs.

MOC® has since blossomed into a massively bureaucratic and lucrative industry. Hundreds of commentaries by physicians lament this costly, ever expanding, and burdensome leviathan. Top selling magazines and books have also jumped on the criticism bandwagon. Salacious stories of alleged financial impropriety plaguing the American Board of Internal Medicine now cast shadows of distrust over its brethren boards, which have collectively amassed a half-billion dollar war chest thanks to their newfound annuity called MOC®. All the while, credible evidence demonstrating that MOC® meaningfully improves patient care remains scant at best.

The ABMS claims that each member board “is a physician-led, non-profit, independent evaluation organization whose accountability is both to the profession and to the public.” In reality, though, there is little accountability—to either physicians or the public. Accountability is largely illusory, with certification boards answering only to their ABMS fraternity brothers. As a result, ever changing board mandates go unchecked, as the ABMS proudly proclaims that “boards are not membership societies.” Translation: “we are beyond reproach.”

But that’s not true. There are, in fact, very real mechanisms by which physician professional societies can hold their sponsored boards accountable—but only if they so choose. Remember, those boards were founded with the sponsorship of the American Medical Association (AMA) and many other professional societies. Some boards, including my own, prominently highlight those sponsors on their websites, publicly connoting ongoing endorsement. Those sponsoring societies, however, demand no formal, transparent, and ongoing accountability of the boards that so proudly leverage their brands. If a sponsor truly “assumes responsibility for some other person or thing,” then professional societies must reconsider prior decisions to assume responsibility for the boards their dues-paying members increasingly vilify and distrust.

The ABMS member boards have all made it clear that one-time physician certification is inadequate to ensure lifetime accountability. If so, then isn’t one-time sponsorship inadequate as well? If MOC® is a good and righteous mechanism of ensuring accountability, then MOS (Maintenance of Sponsorship) should be good and righteous as well.

Here’s the crux of MOS: if a board wants a professional society’s ongoing sponsorship, then it needs to play by that society’s rules. MOS, like MOC®, is essentially brand licensing—and based on MOC®’s four-part roadmap:

1. Professionalism and Professional Standing. As with physician state licensure, boards seeking ongoing sponsorship would need to demonstrate good standing with the ABMS or the National Board of Physicians and Surgeons (NBPAS).

1. Lifelong Learning and Self-Assessment. For physicians, this is MOC®’s mandatory continuing medical education (CME). Under MOS, all directors of sponsored boards would annually be required to attend 25 hours of targeted education to ensure familiarity with the contemporaneous and varied practices of those they’re certifying, as well as the financial and administrative ramifications of the regulations they impose. Further, board leaders should undergo approved real-time testing on this content, akin to physician self-assessment CME (SA-CME) now mandated under MOC®.

1. Assessment of Knowledge, Judgment, and Skills. Initial and ongoing examinations are the cornerstones of physician certification, and even today, many are administered orally. So, as a condition of ongoing sponsorship, the AMA and other professional societies should require directors of sponsored certification boards to participate in open panel discussions, and be “tested” by professional and public stakeholders on their knowledge of real world practice, judgement, and communication and leadership skills—and be scored accordingly. If the public is to trust these individuals to police physicians, then it deserves to know if they are worthy of that trust.

1. Improvement in Practice. MOC®-imposed quality improvement projects are essentially self-research, intended to help physicians improve upon things they’re doing in their own practices. Under MOS, sponsored boards would similarly be required to undertake credible research to show how they’re performing. I, for one, eagerly await evidence showing that MOC® improves patient outcomes.

Unlike MOC® rules developed in smoke-filled back rooms, MOS would be an inclusive, open, and fully transparent process to ensure that boards are truly accountable to “both to the profession and to the public.” Physicians, patients, and other stakeholders could all participate in public MOS rulemaking. And, as a condition of ongoing professional society sponsorship, boards would be subject to equally open scrutiny of all new and ongoing initiatives, requirements, and regulations. Any certification board, of course, could simply decline to pursue sponsorship. The resulting accountability silence would, however, be deafening.

If MOC® really ensures professional and public accountability, then we need to take it a step further and pursue MOS post haste. But, if MOS is deemed fundamentally unwieldy, ineffective, or just plain silly, then it’s time reflect more carefully on its predicate MOC®—and whether our boards remain true to the guiding missions of their visionary founders. Real accountability cannot be a one-way street.

Richard Duszak, Jr., MD (@RichDuszak) is Professor and Vice Chair of Radiology at Emory University and Associate Editor of the Journal of the American College of Radiology. He was recently recognized by the American Board of Radiology with its Volunteer Service Award for his many years of dedicated work as an oral examiner and examination creation and evaluation committee member.

BY LINCOLN WEED, JD

“Patients are sitting on a treasure trove of data about their own medical conditions.”

My late father, Dr. Lawrence L. Weed (LLW), made this point the day before he died. He was talking about the lost wealth of neglected patient data—readily available, richly detailed data that too often go unidentified and unexamined. Why does that happen, and what can be done about it?

The risk of missed information

From the very outset of medical problem-solving, LLW argued, patients and practitioners face greater risk of loss and harm than they may realize. The risk arises as soon as a patient starts an internet search about a medical problem, or as soon as a practitioner starts questioning the patient about the problem (whether diagnostic or therapeutic).

This gap creates high risk that information crucial to solving the patient’s problem will be missed. And whatever information the mind does deliver is not recorded and harvested in a manner that permits organized feedback and continuous improvement.Ideally, these initial inquiries would somehow take into account the entire universe of collectible patient data and vast medical knowledge about what the data mean. But such thoroughness is more than the human mind can deliver.

Guidance tools set standard of care

The only secure way to proceed, LLW concluded, is to begin investigation of medical problems (the “initial workup”) using guidance tools external to the mind. These tools must couple patient-specific data with general knowledge as follows:

• Link the initial data point (i.e., the patient’s presenting problem) with (1) medical knowledge about potentially relevant options and (2) readily available data for identifying those options (see the outer circle in the diagram below);
• Link the data in (2), once collected, with the knowledge in (1) to show how well the data match up with the combinations of data points defining each relevant option—this matching indicates which options are worth considering for the individual (see the middle circle in the diagram below); and
• Organize this information (data coupled with knowledge) into options and evidence—that is, diagnostic possibilities or therapeutic alternatives, the combined findings (positive, negative, or uncertain) on each alternative, and additional knowledge useful for assessing the best option to pursue (see the inner circle in the diagram below).

Tools to carry out these steps would define best practices and make them enforceable as high standards of care for the initial workup (i.e., patient history, physical exam, and basic lab tests). That threshold task is pivotal. It lays the informational foundation for follow-up thought and action by the patient and practitioner. That foundation is also needed for feedback activities to and from third parties. (See the diagram on p. 13 of Medicine in Denial.)

Patient-driven tools

In carrying out the initial workup, the patient’s role is always central. The tools should enable patients to enter history data, which is often the most detailed component of the initial workup. Moreover, the patient necessarily participates in the physical exam conducted by the practitioner, and reviews history, physical, and lab findings with the practitioner.

Tools for the initial workup must thus be used by patients and practitioners jointly. But patients must be able to initiate use of the tools unilaterally. They can’t rely on practitioners to recognize when serious medical investigation is needed. Patients are the ones who experience symptoms—who notice changes from what feels normal. To investigate whether these symptoms might be medically significant, patients need web-based tools for problem-specific inquiries. So do healthy persons who may simply require periodic screening checkups for unidentified problems (plus initial workup of any problems discovered).

Overcoming the medical Tower of Babel

Whether it is patients or practitioners seeking guidance for the initial workup, traditional medical practice leaves them both in a vacuum. Once that vacuum was filled solely by practitioners’ idiosyncratic judgments. Now the vacuum is also being filled with a plethora of practice guidelines and clinical decision support tools, not to mention internet search engine tools.

But the very multiplicity of all these resources defeats the purpose of defining generally accepted, enforceable best practices for initial workups. And the multiplicity is increasing with new patient-generated health data from sensors, wearables, and smartphone-connected devices for physical exam data.  Moreover, the universe for needed guidance is expanding with vast new genomic/molecular data and knowledge.

The outcome of this multiplicity is not useful diversity but a Tower of Babel.

What we need instead are information tools with a unified design and trustworthy medical content, tools that guide users through the basic steps for inquiry into all medical problems, tools that take into account relevant information from all specialties without intellectual or financial biases. Users should not have to switch back and forth among different tools and interfaces for different medical problems, different specialties, different practice settings, different data types, different vendors, and different classes of users. The medical content captured in the tools must be problem-specific, but the tools’ basic design (see the three bullets above) should generalize to all problems in all contexts, as much as possible. This generality enables intuitive ease-of-use at the user level and powerful synergies at the software development level.

NLM’s role for the 21st century

LLW saw NLM as key to developing tools of this kind.

Drawing on its uniquely comprehensive electronic repository of medical content, NLM could create a new repository of distilled, structured knowledge. Drawing on its connections with the NIH research institutes and federal health agencies such as the CDC and FDA, NLM could rapidly incorporate new knowledge into that specialized repository. Outside parties and NLM itself could use that repository to build user-level tools with a unified design for conducting initial workups on specific medical problems.

This new infrastructure will encounter a barrier to its use—the medical practice status quo. Not all practitioners (or their overseers) will accept the data collection demands defined by the tool.By enabling creation of such a knowledge infrastructure for the public, NLM would seize an “opportunity to modernize the conceptualization of a ‘library.’” Beyond its current electronic repository, NLM could be “demonstrating how information and knowledge can best be developed, assimilated, organized, applied, and disseminated in the 21st century.”  [NIH Advisory Committee to the Director, NLM Working Group, Final Report, p. 12 (June 11, 2015).]

Patients at the center

Here we return to the central role of patients.

Patients who unilaterally use NLM tools to complete the history portion of the initial workup can then seek out practitioners who are willing (and permitted) to use the same tools for the physical exam and basic lab test portions. By creating demand for those innovative practitioners and using the tools jointly with them, patients can drive medical practice toward a foundational reform.

Lincoln Weed, JD, Dr. Lawrence Weed’s son, practiced employee benefits law in Washington, DC for 26 years. He then joined a consulting firm where he specialized in health information privacy. He is now retired.

By SUHAS GONDI

As the Senate debated the fate of the Affordable Care Act (ACA) in Washington this past summer, healthcare was front and center in newspapers and conversations around the country. While insurance coverage and the affordability of care certainly warrant the level of nationwide attention they received, they comprise only one dimension of the systemic deficits in US healthcare: access to care. Meanwhile, the pressing need to reform our broken delivery and payment structures and address the more than $1 trillion of waste in our system was being overlooked by lawmakers in DC.

Luckily, on the other side of the country, entrepreneurs and venture capitalists throughout Silicon Valley are paying plenty of attention to opportunities to improve the efficiency of healthcare. In the first quarter of 2017, while policymakers fought about repeal-and-replace, investors poured almost $1.5 billion into digital health startups (mostly in the San Francisco Bay Area). This is on top of over $29 billion invested in healthcare startups between 2010 and 2016. Many of these budding companies are poised to significantly improve the way healthcare is administered and enhance the experience of providers and patients in novel, tech-enabled ways. Unfortunately, in addition to the myriad barriers facing any new startup, healthcare startups also encounter several unique obstacles rooted in policy failures that severely limit their potential to disrupt a system badly in need of disruption.

Continue reading →

By STEVEN FINDLAY

The latest Republican attempt to repeal and replace the ACA looks a lot like what they were trying to do in May, June and July—and failed to do.

But actually, the framing of the current effort—the Graham-Cassidy bill—is much more deeply grounded in the perennial debate over where political power resides in the U.S.:  the federal government or the states.   Graham-Cassidy also more starkly reflects what many conservatives are trying to achieve in health care policy.   And what they are trying to achieve is, to put it euphemistically, not nice.  

On both counts, this renewed debate resonates politically beyond health care.  It’s no coincidence that the two Senators behind this new push, Lindsey Graham and Bill Cassidy, are from southern states—South Carolina and Louisiana, respectively.   Before the Civil War, during the Civil War, and up to the present day, southern conservatives like Graham and Cassidy—more passionately than their northern counterparts—have pushed to devolve power to the states and weaken the federal government.

Conservatives in the western states have, for their own set of reasons, come to fiercely embrace this philosophy, too—broadly called federalism.     

A new book—“Democracy in Chains—The Deep History of the Radical Right’s Stealth Plan for America” by Nancy MacLean explores the southern roots of modern conservatism, with a spin that is chilling in the context of the current health care debate.   (An excellent review of the book by Sam Tanenhaus in the July-August issue of “The Atlantic” is my source.)   

MacLean argues, according to Tanenhaus, that southern conservative philosophy has been and still is deeply grounded in the idea that government does not and should not exist to “foster dependency” in the population, initiate programs to help the poor or middle class, or reflect majority rule.  Indeed, the majority can’t and shouldn’t even be trusted.   

Rather, government’s role is to maximize individual freedom and liberty.  Moreover, says Tanenhaus, government’s “misguided Good Samaritanism by helping the unlucky cushions them against the consequences of their bad choices.”  

This was exactly the sentiment, Tanenhaus writes, of the House Republican who explained his vote to gut the ACA and remove pre-existing condition protections by saying the House bill aimed in part to “reduce the cost to those people who lead good lives.”   

As we have all gleaned, the great health care debate of 2017 is about more than health care.  It is about power, very differing political philosophies, moral and ethical principles, the role of government, and I would also say—simply—good and evil.  

Good and evil as they are embodied in political philosophy and the struggle for power, and government policies.      

The conservative approach probed in “Democracy is Chains” reflects the evil impulses of human nature and a belief system that opposes government’s role as a benefactor, force to reduce inequality, or redistribute income.       

That does not mean, of course, that all conservative ideas, conservatives or Republicans are evil.   Nor does it mean that all progressives, liberal ideas and aspirations, and Democrats are all good.   Human nature, social organization, culture and political systems are complex, to put it mildly.    

But, Graham-Cassidy, even more than its predecessor bills, exudes the worst (evil and inhumane) impulses and ideas that reside in the conservative approach to health care that has emerged this year.   

As has been widely reported in recent days, it would reduce the number of people with insurance and government funding for health care for low and middle-income people.   It would dramatically shift the health care policy path we’ve been on since 1965.   

Graham-Cassidy’s framework of devolving power over health care design and decision-making to the states vastly overreaches, creating chaos and harm to consumers.   And it uses state flexibility as the proverbial wolf uses a sheep’s sheared fleece as he sneaks up on the flock.  

The balance of health care power between the feds and states is a delicate and complex system that has evolved over years.   While far less than perfect and somewhat Rude Goldberg (Medicaid!), the system has a certain stability.  Upending it in one fell swoop, even if phased in, is beyond dangerous.   

That said, there is merit is exploring more state flexibility, as moderate conservatives like Stuart Butler (now at Brookings; google his writings) have pushed for years.   

As readers of THCB know, the ACA contained a mechanism for that—in section 1332.  Bipartisan deliberations in the Senate HELP committee, underway now, to stabilize the ACA marketplaces for 2018 and 2019 are exploring changes to Section 1332 to allow states more leeway to experiment.  

A stake should be driven through the heart of Graham-Cassidy’s—befitting the evil it represents.  The HELP committee’s deliberations should be the priority as 2018 open enrollment fast approaches.    

By ASHISH JHA, MD

Austin Frakt and Aaron Carroll recently approached me about a New York Times UpShot piece aiming to rank eight healthcare systems they had chosen: Australia, Canada, France, Germany, Singapore, Switzerland, the United Kingdom, and the United States. This forced me to think about a pretty fundamental question: what do we want from a healthcare system?

I would argue that most people want a healthcare system where they can get timely access to high quality, affordable care and one that also promotes innovation of new tests and treatments. But underlying these sentiments are a lot of important issues that need unpacking. First, what does it mean to be able to access care when you need it? A simple way to think about this is being able to see a doctor (or other healthcare professional) quickly and easily and in cases where there are follow-on tests, procedures, and treatments, you can get them without much delay. This brings up one important point: while experts often discount the importance of timeliness, regular people generally don’t: anyone who has waited weeks or months for a follow-up after an abnormal test result or to get a needed surgery knows that waiting times are not just an inconvenience. Delayed access can be stressful, agonizing and in some instances, downright harmful.

Beyond access, of course, we want care we can afford. Almost all of us need some sort of insurance that would pay for an unexpected, catastrophic healthcare expense (like spending a few weeks in an ICU). Most of us need some sort of financial coverage for other, slightly less expensive services such as an MRI or a knee replacement. And even still, some of us will struggle to pay for simpler things like doctors’ visits and need financial help there as well.  There is broad consensus that we want a healthcare system where people aren’t denied the services they need because they can’t afford them.

While accessibility, timeliness, and affordability are key, there are other aspects of care that get less attention but are just as important: we want care that is safe and effective and produces the best outcomes possible.  It’s great if you can have timely cardiac surgery and pay little or nothing out of pocket. But if you die unnecessarily from a preventable error, you didn’t get what you needed from the healthcare system.

Finally, we want a healthcare system that creates new knowledge so that we get better at caring for sick people. One of my earliest memories of medical school was caring for a young woman, an artist with two small children, who died of a complication of chronic myelogenous leukemia after a bone marrow transplant. Today, her disease could have been managed by a simple, daily pill that has turned CML into a chronic, yet manageable disease.  A system that generates new therapies that save lives is critical and its importance is often overlooked when assessing health system performance.

Health System Organization

So what is the ideal way to organize a healthcare system to accomplish these goals? One school of thought believes that market-based systems are the solution because they rely on competition, customize care for individuals, keep prices down, and allow the highest quality providers to flourish. For others, the answer is a government-run, single-payer system where everyone has equal access, gets comparable quality, and patients don’t have to worry about costs because the government takes care of it. While either approach can be supported with selected data and facts, as I have looked at health systems from around the globe, one theme becomes obvious: systems organized very differently can achieve comparable levels of performance and no single approach consistently outperforms others.

So which countries have the best systems? As the UpShot piece outlines, we did a tournament-style competition where in each round, we had to pick winners and losers.  At the end, we were also asked to rank the selected 8 countries based on our overall assessment. To do so, my approach was simple. Health systems should be judged not by how they are organized (i.e. markets or government) but what they produce. How well does it do what a healthcare system ought to do? So that’s the approach I took.

Evaluating Health Systems

That leads us to the next question: what metrics should we use? If you made it to the first day of a health policy 101 class, you learned about two metrics: per capita spending and life expectancy.  If you made it to the second  class, you learned that unfortunately, these are far too crude to tell you much about health system performance and do not help generate an actionable set of policy prescriptions.  Health care spending is driven by many factors, including what is encompassed in spending calculations (research and development? medical education?) and prices (if one country pays its nurses half as much as another – does that mean the first is twice as efficient?).  Life expectancy is even more complicated as it is driven in large part by behavior, lifestyle, and genetics of the underlying population. As Irene Papanicolas and I point out in our recent JAMA piece, drawing these boundaries when comparing healthcare systems is important.

So if we can’t just look at those metrics, what else should we examine? While one could evaluate literally hundreds of metrics, I prioritized 16 (see Table 1).

None of these are perfect but they seemed reasonable to me – a few on access, quality, cost and innovation. Ultimately, I was interested in assessing performance in areas that are clearly within the purview of the healthcare system – how many people are covered and covered for what? How quickly can you see someone when you’re sick? How good is the system at taking care of you when something terrible happens, like you have a stroke or a heart attack? Does the system generate lots of innovation so that everyone’s care gets better over the time?  I tried not to overly weigh any one of these but tried to look at them holistically.

My Rankings

Based on these measures (for country data, see Table 2), my ranking of the selected health systems is as follows:

1. Switzerland
2. Germany
3. U.S.A.
4. U.K.
5. France
6. Australia
7. Canada
8. Singapore

A few caveats.  First, these are all very good healthcare systems – and we’re generally comparing systems that are far superior to much of the rest of the world. Second, there was rarely a clear winner in head to head competitions.  Switzerland and Germany both have excellent systems and reasonable people could draw a different conclusion from the same data. I struggled among the U.S., France, Australia, and the U.K., all of which had clear strengths and clear challenges. Singapore lagged behind in large part because there is so little data about their performance and lack of data means it might be better than it looks, or it could be worse. I just don’t know.

The ranking of the U.S. above places like France and the UK may be surprising. Some people will point, rightly, to the fact that the U.S. has the highest spending in the world yet still has people who are uninsured. The healthcare spending problem of the U.S. is largely a political choice – we have extraordinarily high prices on everything from physician salaries to pharmaceuticals.  While some of these high prices may spur innovation (i.e. pharmaceuticals), the cost of spending nearly 20% of our GDP on healthcare means less money for everything else. We could do better with different policy choices.

On the issue of universal coverage, things are a bit more complicated. While its narrowly true that the U.S. is the only country here without universal coverage, it’s too simplistic.  First, 91% of Americans are now insured (thanks in part to the ACA).  Some countries have universal coverage for their citizens but not necessarily for immigrants or other groups. Second, it is important to consider what is actually covered.  While most Americans can get access to the latest treatments, in many countries, access to the most expensive therapies can be difficult or non-existent.  I don’t know if we will get to 100% coverage but we are inching towards it and I hope that with the next set of policy reforms, we can get into the high 90’s.  And that would be good.

Finally, if you take a big step back and look at the data, Americans do better than average in timely access, especially to specialty services and “elective” surgery (which is often not that elective).  They tend to be among the leaders in acute care quality, when healthcare means the difference between life and death, although the quality of primary care could surely be better.  And America is the innovation engine of the world, pumping out new drugs and treatments that benefit the whole world.  All of that earns America a high rank in my book – behind Switzerland and Germany but ahead of others. You can disagree but overall, while the U.S. healthcare system has a lot of work ahead, we should not overlook its strengths – and they are sizeable.

So here’s the big picture: when it comes time to measure health system performance, it’s important to think about boundaries (what is the responsibility of the healthcare system and what isn’t).  It’s also important to consider whether the system is delivering what people need: coverage of a broad range of services, especially those that are important for the sickest among us, timely access to affordable, high quality care, and innovation that ensures care gets better over time.  For most people, whether the system is market-based or government-run matters a lot less than whether it’s meeting their needs. And that’s the way it should be.

BY MADHAVI VEMIREDDY, MD            SPONSORED CONTENT

Our day-to-day interactions with technology are changing expectations and aspirations for almost every touch point in modern life. We want instant feedback and action at the push of a button, from the digital shopping cart to the doctor’s office. That is part of why there is a constant stream of new apps and tech services being released across every industry, including wellness. But the barrage of options can be a problem of its own nature.

To better understand what people want and how to deliver resources that resonate and stick, we spent time studying how real people engage (or don’t) with personal health and well-being. What we found was instantly familiar yet full of deeply personal insights that made the struggle real and the solution obvious.

So often we design towards an end-goal or finish line. As we were reminded through our research, health is not static. For the healthy, those with chronic conditions, those actively managing to avoid serious health issues, the issues are all the same: it’s a challenge to live your healthiest life every day. It’s a daily struggle to avoid the foods we shouldn’t eat; it’s a daily struggle to exercise; it’s a daily struggle to live in the “white space” between doctor appointments.

To help people, we need to not only design solutions that fit into their daily lives with convenience and ease, we need to give them help that works in real life. We need to design technology that works alongside people through the ups and downs. This can be tough for well-being programs as we often need to fit these tools alongside program components driven by larger initiatives and deadlines, but it can be done.

A good place to start rethinking program design is understanding the three simple criteria for a consumer-friendly program. Check out our three quick tips to learn the basics for designing a health and well-being program that resonates with employees by putting real people at the center of every interaction.

Madhavi Vemireddy, MD, is Chief Medical Officer and Head of Product Management, ActiveHealth Management

By PAUL KECKLEY

Last week, the Senate Health, Education, Labor and Pensions Committee wrapped up hearings focused on stabilizing the individual insurance market leaving unresolved an issue that separates Dem’s and Rep’s on the committee: just how much freedom states should have in managing their insurance markets. At issue are the Section 1332 waivers which allow states to reduce essential benefits in health insurance policies, thus allowing insurers to sell policies that cover less with lower premiums.

Also last week, Republican Senators Lindsey Graham and Bill Cassidy offered what they called the “last chance” for Republicans to repeal and replace the Affordable Care Act. Their bill would repeal the individual and employer mandates and replace the ACA’s tax credits, Medicaid expansion, and cost-sharing payments with block grants to states so governors would have more flexibility and authority in managing their Medicaid programs and insurance markets.

But arguably more media attention was directed at Sen. Bernie Sanders’ proposal to replace the current employer-sponsored health insurance system with “Medicare for All” which would be phased on over four years and be funded by increased employer payroll taxes and higher taxes for those earning more than $250,000. What appeared to garner the media’s attention was the cadre of 15 Democrats in the Senate and 117 in the House who endorsed his proposal, though its price tag is unknown.

The notion of Medicare for all, or a single payer system, is not a new idea. Public opinion is mixed. A Kaiser Family Foundation poll in June found 57% of Americans favor the concept of Medicare for All. An Economist/You Gov poll in April reported that 60% of Americans think “Medicare should be expanded to cover everyone”.  And polls by Politico, Rasmussen and Pew have shown favorable responses by 2 in 5. But questions about how a single payer system would work are widespread and like so many issues, complicated. Here’s my take:

The concept of a single payer system is gaining in popularity and will be the centerpiece of the 2020 Presidential election. The public’s not happy with our current system and it’s clear in polling that we’re a soft target. Insurers are not trusted, drug companies are considered greedy, hospitals are thought to be wasteful and physicians appear more concerned about their incomes and control than their patients. Those on Medicare are happier with their coverage than those with private coverage and employers are shifting more costs to their employees directly or suspending benefits altogether. And after 7 years of contentious debate about the Affordable Care Act, there’s a fundamental divide in our land: half believe healthcare a right that the federal government should guarantee and the other think the federal government, if given more control, will ruin it. The public thinks Congress is more about partisan wrangling and getting elected than problem solving so that’s where we are. But while divided about the Affordable Care Act, the majority think access to healthcare is a fundamental right and insurance coverage an advantage in obtaining it.

Tracking polls by Kaiser, Harris, Pew and others show consistent increases in the numbers of citizens who think the current system is broken—too expensive, too complicated and too focused on profit—and the majority want something better. Public opinion polls by Deloitte and others show healthcare systems in Switzerland, France, Canada, the UK and others get better grades from their citizens than does ours. So, the notion of a single payer system, though not understood, will gain momentum as a defining issue in Campaign 2020 especially among Democrats who aspire to be in the White House one day.

Acceptance of the trade-offs inherent in a single payer system will spark fierce debate. For most Americans, understanding what exactly a single payer system is and how it might work is not deep. Usually, single-payer healthcare is described as a healthcare system financed by taxes that covers the costs of essential healthcare for all legal residents. Alternatively, a multi-payer system, like what we have in the U.S., is one in which private individuals or their employers buy health insurance or healthcare services along with purchases made by the government for designated populations.

In some single-payer systems, like the Canadian system, private hospitals and doctors contract with the provincial government to provide care for patients. In others, like the U.K. National Health Service, providers are employed by the NHS to provide services to patients with allowance for outside work with private patients. And there is wide variety in single-payer models among the developed healthcare systems in Europe, North America and South America, parts of Asia and the Mediterranean.

In the U.S., our national discussion about a single payer system will likely focus in two broad areas:

1. Costs: in single payer systems in developed countries, the legislative process determines priorities for budgeting, usually tied directly to the growth rate of the economy and an acceptable investment in healthcare. Healthcare is usually 6-13% of a country’s GDP (vs. 18% in the U.S.) and funding includes social services in addition to direct patient care activities. And in most single payer systems (not all), individuals pay part of their tab and some purchase private insurance to cover their out of pocket expense or get access to services not covered by the government’s coverage.The U.S. debate will center on two issues: the relatively high prices we pay for the drugs, devices, technologies, services and facilities we use, and the medical necessity for many services provided for which evidence shows no benefit. What happens to innovation if the federal government uses its muscle to ratchet down what it pays for services and who decides what’s necessary or not? And what’s the administrative expense necessary to managing our $3.4 trillion expenditure? Senator Sanders Medicare for All has not been costed by the Congressional Budget Office but most expect it to cost more than the status quo. Some counter it will cost less because administrative costs will be half what private insurers pass through in premiums and the government will use its muscle to drive down prices for drugs and everything else it buys. But no one knows for sure.
2. Structure: in developed single payer systems, primary and preventive health is the front door to the system. Physicians and mid-level providers authorize access to specialists acting as gatekeepers. Coordination of social services with medical care is formalized adding 3-5% to the total costs of care. A government agency/board determines priorities for the system and allocates funding accordingly. Rationing of services and programs is standard operating procedure and end of life care is less institutionalized. In the U.S., primary care is subordinated to specialty medicine unless a provider organization accepts long-term risks for a population’s costs and outcomes. And primary care is fragmented and incomplete: dental care, mental health, nutrition and health coaching are not effectively or consistently integrated with physical medicine and medication management.

   The issue will be whether and how primary and preventive health will be elevated in a U.S. single payer model and how specialty and long-term care are impacted long-term. If the appetite of American taxpayers is for modern facilities and unfettered access to specialists at will, there will be tension.

In the interim, the Affordable Care Act will be the law of the land, though with tweaks resulting from executive orders and administrative actions that address its primary aims: to change incentives from fee for service to value and to increase access to insurance coverage for those without. But attention to the allure of a single payer replacement will increase, and with it public debate about how it should be structured and what it should cost.

By ALYX STERNLICHT                             SPONSORED CONTENT

The tech industry is notoriously lacking diversity. Health tech also lacks diversity in both the innovators creating technology and the technology targeting diverse users.

Last Fall, at Health 2.0’s annual conference, Health 2.0, with support from the Robert Wood Johnson Foundation, hosted a panel focusing on minority entrepreneurs and building tech products for underrepresented groups. The discussion that followed the panel was a passionate and thought provoking conversation. Some feedback included questions like: “Why isn’t this discussed more often?” and “there is dire need for inclusive products and support of underrepresented groups in tech.” With that feedback Health 2.0 decided to do something about diversity in health tech.

In January, TECHquality, a mentorship program for individuals who are underrepresented in health tech, paired those individuals with leaders in the health tech space. Underrepresented groups include, but are not limited to: People of Color, Women, LGBTQ, Veterans, People with Disabilities, etc. With over 200 applications for mentors and mentees, 80 mentor/mentee pairs were matched based on areas of interest and expertise. After a 4-month long mentorship program, 96% of participants who met at least once a month agreed the mentorship program was worthwhile and impactful on their career and 94% of participants who met at least once a month agreed that the program matched them with a mentor/mentee that fit their area of need/expertise.

With support from the Robert Wood Johnson Foundation, Health 2.0 is excited to begin another open application for TECHquality. Potential mentees and mentors are encouraged to apply here by 10/18. The program will officially start November 2, 2017 and run through early March, 2018.

Is your organization interested in making actionable impact to close the diversity gap Partnership and sponsorship opportunities available? Email alyx@health2con for more information.

Alyx Sternlicht is a Senior Program Manager at Catalyst @ Health 2.0.

ANISH KOKA MD

In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.

Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear.  He loved guitar playing,  and camp horror movies.  Those who knew him well said he had a kind heart, a quick wit and loved cats.

I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon.  I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack.  Not able to make sense of the story on the phone, I was in to try to sort it out.  Joe was gruff, short with his answers – but clearly something just wasn’t right.   He was only 54 but had more problems than the average 50 year old.   Progressive calcification of his aortic valve  some years ago  had caused intolerable shortness of breath resulting in  replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis,  and most recently abnormal liver tests had  revealed the presence of the early stages of cirrhosis from hepatitis C.  Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.

But on this particular day it was readily apparent Joe was not well.  It didn’t take long to figure out that Joe had an infection somewhere.  He had come in feeling hot at times, but having chills at others.  Review of his ECG, stored telemetry in the ER revealed a conduction disturbance not infrequently seen called a left bundle branch block, as well as a rhythm disturbance called atrial fibrillation , but no evidence of a heart attack  that had prompted the ER to call me.   I told Joe and is anxious wife that he needed to be admitted to the hospital to find where the infection may be coming from.

Joe had a number of places he could be harboring an infection.   While dialysis maybe one of the modern marvels of the world, the concept is fairly crude. In the absence of functioning kidneys an artificial machine does the work of the kidneys. Via large catheters the patient’s blood is removed, circulated through the machine and then returned to the patient.  The flow required to circulate enough blood over a course of three hours involves creation of large conduits between arteries and veins, or placement of artificial grafts.   Every access of these vessels with dialysis sessions  carries a risk of introducing bacteria into the bloodstream, making infections a common event in this population.  Complicating matters further, Joe had an artificial heart valve,  which lacking the natural immunity of native heart valves,  are especially prone to seeding by bacteria.

I told the admitting team that if no other source of infection became immediately obvious he would need an ultrasound to more closely examine his valve. That night I was called by the overnight resident in the hospital because Joe had a low heart rate. He felt fine,  and his blood pressure was OK .  I stopped a heart rate lowering medication that he had been on hoping this may be the cause.   The next morning a review of his electrocardiogram and recorded telemetry demonstrated an ominous finding – episodic heart block.   The heart’s four chambers are segregated into two small upper chambers that contain the pacemaker function of the heart and two lower chambers  that are the powerful mechanical pumps which circulate blood.   The upper chambers are electrically insulated from the lower chambers except for narrow specialized bundles of tissue that function as electrical cables.   The specialized conduction fibers form an intricate lattice that allows the normal heart to contract  in less than 100 ms.  The weak point is a narrow isthmus in close  proximity to the  aortic valve that the electrical bundles must navigate near their origin.   In Joe’s case, the electrical bundles were conducting in a stuttering fashion because bacteria was eating away at precious cardiac tissue surrounding the artificial valve.

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