Regarded

By CHELSEA POLANIECKI

Ever step out of your doctor’s office feeling overwhelmed and instantly forget all of your doctor’s instructions? Instinctively, you look down to your phone to check your texts and emails–wait, no. Instead, you look down to your phone and see that your doctor has asked you to get an X-ray and you need to pick up your Advair prescription. You can see your options for local imaging centers and pharmacies, and what they will cost you, based on your specific insurance plan and location, right on your phone before even getting home. Well, that’s new.

The days of being rushed out of your doctor’s office and forgetting your care plan are over, thanks to the Choosing Care Challenge sponsored by the Robert Wood Johnson Foundation. The challenge, launched at Health 2.0’s Wintertech on January 11th, 2017, encouraged the development and advancement of technologies that help patients and providers identify and locate prescriptions, imaging labs, and specialists, all to fit an individual’s specific needs. Participants were equipped with resources such as APIs and data from PokitDok and Vericred. With over sixty initial Phase I applications, solutions ranged from chatbots, to web platforms and AI apps. The applications were reviewed by a panel of expert judges and narrowed down to five finalists, each awarded $5,000 to further develop their solutions.

For Phase II of the challenge, each of these five finalists were required to prove that their app or tool is more effective than the others. They displayed the app or tool and how it would be used in a short video, and provided the working solution itself for the judges to interact with in real time. The judges evaluated each submission based upon the following four criteria:

• How helpful is the solution to patients?
• How strong is the solution’s potential for scalability?
• How effective is the UI/UX design for user friendliness?
• How impactful is the solution for patient-specific needs?

The challenge prompted participants to “make it simple,” and that they certainly did. Phase II winners made health care decision-making especially simple.

Taking home first place, with a grand prize of $50,000, is (drumroll please) Stroll Health (@StrollHealth). Also a previous winner of Traction 2016, Stroll has built a seamless web platform that enables health providers to send patients directly to local imaging centers and specialists, and helps to manage prescriptions. Stroll’s easy-to-use platform provides automatic referrals, prior authorization and real-time scheduling. For the challenge, Stroll expanded their platform to include hundreds of thousands of specialists and more than five thousand prescriptions across the nation. Let Matt and Jordan walk you through the platform themselves in this video.

Coming in second place, with a prize of $15,000, is Moment (@momentdesign). Moment created “Orderly,” a web based platform which allows patients to receive up-to-date lists of preferred specialists, imaging labs and pharmacies. Patients can also use Orderly to view data such as cost, coverage and location, and even schedule next steps through provided contact information and online booking tools. “Orderly” builds on the relationship between patient and physician to understand, discover, and choose referral options together. See how it works here.

And finally, the third place prize of $10,000 goes to Project Helix (@kcdigitaldrive). The solution includes a chatbot within a mobile application to help patients navigate their prescription costs with convenience in mind. The solution is a low-tech interface with complex data-driven decisions on the backend. The chatbot connects with the patient each step of the way via text notifications and API data, tailoring results to the patient’s needs. Learn about how this chatbot makes it simple here.

So, next time you leave the doctor’s office scratching your head, just look down at your phone and relax because all of the information you need will be right there waiting for you with help from these challenge winners

To learn more about Catalyst @ Health 2.0 and other programs or opportunities, subscribe to our Newsletter, and follow @catalyst_h20 on Twitter.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

ANISH KOKA, MD

There are 80,000 new cases of primary brain tumors diagnosed every year in the United States.  About 26,000 of these cases are of the malignant variety – and John McCain unfortunately joined their ranks last week.  In cancer, fate is defined by cell type, and the adage is of particular relevance here.

Cancer is akin to a mutiny arising within the body, formed of regular every day cells that have forgotten the purpose they were born with. In the case of brain tumors, the mutinous cell frequently happens to not be the brain cell, but rather the lowly astrocyte that normally forms a matrix of support for brain cells.  Tumors made up of astrocytes are called astrocytomas.  Classification schemes for brain tumors in the era of molecular subtypes has grown enormously complex, but a helpful framework is provided by the appearance of these tumors under a microscope.  Grade 1 tumors are indolent, with little invasive capacity, while Grade 4 tumors are highly invasive, marked under the microscope as dense, sheets of cells that can even be seen to grow their own blood supply.  Senator McCain has a grade 4 astrocytoma, otherwise known a a glioblastoma (GBM) – the worst kind.   Social media from all sides of the political spectrum lit up with well wishes – with most casting the disease as something to be defeated.

John McCain is an American hero & one of the bravest fighters I’ve ever known. Cancer doesn’t know what it’s up against. Give it hell, John.

— Barack Obama (@BarackObama) July 20, 2017

Others within the medical community took a different take.

GBM sucks & will defeat McCain. “Get Well Soon” is misguided to point of being insensitive.This is where ‘thoughts and prayers’ makes sense.

— Mehreen (@GrrlMD) July 20, 2017

Mehreen is right.  GBM is a deadly disease,  the 5-year survival rate for patients with GBMs is <3%.  The majority of GBM patients live less than a year.  Yet, the medical community of neurosurgeons and oncologists that treat these tumors go to battle with these tumors.  Why?

I asked a very busy neurosurgeon this same question.   I asked him what he told patients. He told me that he never mentions the word cure.  There is no cure.  The goal is to manage the disease and buy more time.

Median survival for GBM is measured in weeks, not years.  Do nothing, and expect 14 weeks; combining surgery, radiation therapy, and chemotherapy may give you 45 weeks.

What we describe is median survival, of course, and as Stephen J Gould eloquently put in his diatribe against statistics in cancer – the median is hardly the message.   The oncologist you want is the one who doesn’t tell you about median survival when breaking the news to you of your cancer – she implicitly understands each GBM has a different path.  Here are three such paths.

Case 1.

Margie is 35 year old redhead who hails from Wildwood, New Jersey, where she helps her parents run a boardwalk diner.  I first met her 7 years ago after she had presented with a seizure.  In this case the seizure was precipitated by a GBM.  A resection of the tumor followed – the postoperative course was complicated by more seizures, and an arrhythmia that brought me into her orbit.  I’m a cardiologist so I didn’t see her again until she returned 7 years later with a surgical wound infection – but with no evidence of cancer recurrence.

Case 2.

Mr. Walker was a 74 year old man with a very sick heart when he presented with difficulty speaking.  A retired executive who was used to being loquacious, he had survived a heart attack with the help of a stent a decade prior, but had been left with disease in little vessels that gave him occasional angina. Otherwise it allowed him to shuttle between his house and his daughter’s house to enjoy his grandchildren.  A granddaughter had a wedding in a few months he was hoping to attend.  The question to me related to his cardiac risk of surgery.   Was there anything that could be done?  He was on anti-platelet blood thinners that would have to be stopped to cut into the brain. Would that be ok?  I discussed the case with everyone – his eldest son was an orthopedic surgeon, and his daughter was a medical malpractice attorney.  I said nothing that they didn’t already know.  He was high risk.  I quoted a 10% risk of a heart attack or death with the procedure.  Mr. Walker wanted to proceed with the proviso that no heroic measures should be undertaken in the case of a complication- in the event of a cardiac arrest, he did not want to be resuscitated.

Five days later,  I received a call from the neurointensive care unit.  Mr. Walker had been out of surgery for an hour, and his heart rate was low.  I was driving to another hospital, but I asked to be sent an electrocardiogram.  What I saw made me turn the car around.  He was having a heart attack.  The stent he had placed some years ago had occluded.  He was having mild chest pain and looked uncomfortable.  Taking him for an urgent cardiac intervention was out of the question. This would require not one but four potent blood thinners – almost certain disaster in a man hours removed from major brain surgery.   Of even more immediate concern was his heart rate.  It was dipping dangerously low – he had developed heart block – a condition where the upper chambers of the heart don’t communicate with the lower chambers.  This disconnect is at times reversible, but other times not.  As his block worsened, there were seconds that would pass with no heart beat at all.  With his daughter at his bedside, I tried to explain what was happening, as I tried to figure out what to do.  After a particularly long pause in his heart rate when he passed out, he made it easy – he told me – “I’m not ready to die today”.   We placed him on a breathing machine.  It took me twenty minutes to thread a wire hooked up to an external pacing box into his heart.  As the wire passed through the upper chambers of his heart, it precipitated a rapid arrhythmia. Diseased conduction tissue conducts even slower when asked to work harder, and the fast impulses from the upper chambers caused a heart rate too slow to effectively perfuse his brain.  He coded.  The wire in his heart wasn’t going where it needed to, and I asked the team to start chest compressions.  A long minute later, wire situated, rhythm restored, I walked out to talk to his daughter who had been observing the events outside.  She wasn’t happy.  She demanded to know what I was doing.  I explained the best I could – he was completely dependent on his pacemaker, intubated and sedated.  I didn’t think he had suffered any significant brain damage from the recent events, but I wasn’t sure how his heart would do as his heart attack completed.  We decided to see how he did overnight and make a decision in the morning.

The next morning I walked into a cheerful Mr. Walker eating scrambled eggs, wire still in place, still pacing him.  What else was there to do?  I explained to Mr. Walker that without his pacemaker he would die – the next day the electrophysiology team placed a permanent pacemaker, and weeks later, a still cheerful Mr. Walker walked into my office with his daughter.

He made his granddaughter’s wedding, but six months later his brain tumor recurred. He died quietly at home a week later.

Case 3

Frank was a large burly 64 year old, accompanied by his wife, wearing a faded Harley Davidson jean jacket adorned with a a bald eagle and an American flag.  He was another man with a cardiac stent heading into surgery for a GBM.  As happens frequently, he asked me as I started to finish up with him if I knew the surgeon and anything about the surgery.  As I shook his hand, I assured him he was in good hands with the surgical team.  He held my hand a little longer and told me that he wanted the best treatment, but he didn’t “want to be hooked up to no machines if there was no hope”.  His resection was uneventful, but a week later he returned to the hospital.  His wife kept a constant vigil as his clinical state worsened.  He had not responded to any commands in days, and a ventilator was breathing for him.  The surgeons and the intensivists told me that his wife would not let him go and wanted everything possible done.  But there was nothing to do.  I couldn’t understand it.  His wife had witnessed our conversation.  I don’t ordinarily discuss goals of care in patients with non cardiac diagnoses.  But I felt compelled to advocate for Frank. I gently reminded his wife of our conversation in the office.  She remembered.   An awkward silence followed, and I slipped up.  I asked her how she could do this.  I regretted the words the moment they left my mouth.  Her eyes took up the flat look of someone being attacked.  I clumsily made my exit, and heard later of her displeasure with my conversation.  I never saw Frank again.  He died a week later, 4 weeks after I shook his hand in my office.

The population health brigade would have us ignore the messages each patient has to give us.  But there is so much here that each patient taught me.  Margie reminded me that median survival isn’t destiny.  Mr. Walker made me appreciate the fog of decision- making in the terminally ill patient.  It is hard to let go of life.  Mr. Walker wanted to live on that day.  Much of the dollars spent on health care in America are decried as wasteful and I imagine that on paper the dollars spent in the last months of Mr. Walker’s life exemplify waste to some.  Yet, you’ll understand how some may see not defeat, but victory in the image of a proud grandfather at his granddaughter’s wedding.  Frank’s story is a tough reminder of what I see all too frequently in a world where patient and family autonomy is sacrosanct – moribund patients kept alive by families that can’t let go. There is a fundamental tension between paternalism and autonomy – go to far in either direction and you end up lost.

There is something insidious about those who take issue with terms like battling, fighting and hope in these patients.  There is a deeply nihilistic message that lies at the core.  You are going to lose – so why fight? Why endure brain surgery, or the radiation or chemotherapy to come? The barbarians at the city gates in healthcare are those who believe the primary role for doctors in this unlucky group of patients is to ferry patients gently into that good night.  Baloney.  Some patients will choose to fight because they want the opportunity to make that next wedding, others will choose to go home.  These are hard decisions best left to the patients and their physicians.  You’ll excuse me if I don’t begrudge those wishing the Senator well in what ever path he chooses.  Give ’em hell, Senator.

Anish Koka is a cardiologist in Philadelphia.  Follow him on twitter @anish_koka

By UWE REINHARDT

The following exchange occurred during an interview of President Trump with journalists of the NYT:

HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.

TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.

President Trump presides over the health-care experience of millions of Americans. Does his answer scare anyone else as much as it scares me?

By KIP SULLIVAN

It’s hard to know what “Trumpcare” is, but whether it’s “repeal” or “repeal and replace with something terrific,” it was and is going to fail. It was either going to fail to be enacted by Congress, or if it was enacted, it was going to set off such a bipartisan backlash it would be repealed, either by a chastened Republican Congress or a new Democratic Congress and president.

The reason Trumpcare was doomed was that health care is not like global warming or police shootings or use of military force in foreign countries: It is an issue a large majority of Americans agree on, and it is an issue voters can assess with their own eyes in their own kitchens.

Republican voters are almost identical to Democratic voters in what they want in a health care system. They want comprehensive coverage, low out-of- pocket costs and affordable premiums, freedom to choose their own doctors (they could care less about freedom to choose between Aetna and Humana), and freedom from interference by bureaucrats (be they public or private). Obamacare became a liability for Democrats because the public clearly perceived that the ACA could not meet those requirement for millions of Americans. The public now clearly perceives Republicans want to enact legislation that would be even worse than the ACA.

These facts — Americans want the same thing in a health care system regardless of party, and it’s difficult for politicians to fool the public about the success or failure of a health care bill — were obvious to thinking people even before the new Republican-controlled Congress began writing their “repeal and replace” legislation. But it was not obvious to Trump and most congressional Republicans. For some reason they thought they could remove 20-30 million people from the ranks of the insured, hand most of the savings over to the rich, and the public wouldn’t mind.

Now they know. The public has a little problem with that.

The good news is that Trump and the Republicans learned before enacting their dreadful “repeal and replace” bill that the public doesn’t like it. The bad news is that Trump is the president, he has the power to accomplish repeal by sabotage, he doesn’t seem to care what happens to the Republican Party now that they elected him king, and he might well force the country to undergo a rough equivalent of repeal without the formal consent of Congress. In that event, we will have to watch Trumpcare die AFTER it harms millions of people who have insurance now, and after it inflicts much damage on the GOP.

Trumpcare was and is doomed. The only question before us is how it will die.

By MATTHEW HOLT

I’ve also been having a bit of fun with creating a new site called SMACK.health, which uses the new .health domain extension. Well you knew you needed both a new definition to replace the fuzzy term “digital health” and .com is so 1999! But what am I talking about when I use the term SMACK.health, and why? I was asked to write a piece about technology in health for USA Today spin-off, and I’ve repurposed it here to celebrate the official .health launch.

There’s a big change coming to our health care experience — driven by technology. Health care is moving from a point-in-time event to one of continuous care. Think of your last doctor’s visit. You probably had a few minutes with a rushed clinician and were sent on your way. The next steps, such as correctly interpreting the instructions, getting prescriptions filled and figuring out next steps was left largely on you. Yet, most conditions, like diabetes, heart disease and asthma, require continual monitoring and management to avoid painful and costly complications. In fact, what happens outside the doctor’s office is more important than that meeting in it.

A new way

Relying on the old point-in-time interventions doesn’t work. To this point, most hospitals and doctors have only had information tools that record what they did in the visit or during the procedure. Instead, SMACK.health technologies will enable clinical teams to perform continuous care. SMAC stands for Social & Sensors, Mobile, Analytics and Cloud. These are the underlying technologies behind what we now use every day — Skype, texting, WhatsApp, iTunes, Facebook, Google, Amazon, et al. To reach patients wherever they are, thousands of relatively new companies are building similar technologies and services that will help a combination of today’s clinicians and tomorrow’s automated artificial intelligence systems manage patients — and help patients manage themselves. And hopefully they’ll be doing it with a big dose of empathy — hence our adding the “K for Kindness” to the SMACK.health lexicon.

Information influx

The other big change is going to come in what we use those technologies to do. For sure, patients are already way, way better informed than they were 15 or 20 years ago. They can access great content online, including information shared by other patients on sites like PatientsLikeMe, MedHelp and Smart Patients. Patients and their caregivers will use those tools to be better informed about their care and inform each other and their clinicians. But that’s not all. We are already seeing services like American Well, Teladoc and DoctorOnDemand (sometimes provided by current health insurers and hospitals) enabling video visits. A whole range of cameras, sensors and medical tools will make those services, and a host of others, better able to connect patients with clinical solutions.

What’s next

We are also going to use new technology to diagnose and treat. Computer algorithms from companies like PhysIQ are already remotely reading abnormal heart rates via disposable patches. Soon, a range of devices will be in the bathroom reading your spit, poop, blood, breath and vital signs. Companies like Philips and Nokia and startups Kinsa, uBiome and CloudDX are bringing them to market. They’ll first be used by the sickest patients, but soon they’ll be mainstream consumer goods. Finally, mental health, physical therapy and more are already being delivered by avatar-based artificial intelligence like Ginger.io and Reflexion Health.

The health care system faces huge changes adapting to the realities of these new technologies. But when it does, it will improve the experience for patients and clinicians. And it will bring patients and society better health outcomes.

Matthew Holt is the publisher of THCB and Chair, Health 2.0 Conferences

By JOHN IRVINE

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation.  As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising. Caught up in the drama of the Watergate-Russia emails-Trump family narrative, major media outlets like the Washington Post and the New York Times see a historic defeat rather than a temporary setback. That may or may not turn out to be true. Predictably, conservative commentators and the alt-right believe the defeat says more about the mainstream media and the Deep State than it does about the Trump Presidency. For their part, Democrats clearly think they have found their issue and can be expected to continue to exploit it using legislative Viet Cong tactics (attack on social media, melt into the jungle, lob snarky public Molotov cocktails) to punish Republicans and keep the story on the front page.

One thing is clear. Instead of repealing and replacing Obamacare, the GOP now has to rewrite and replace its own plan. Doing that would be difficult under the best of circumstances, but in the current climate in Washington it is difficult to see how it would be possible without a major shift in the political landscape.

All of this is bad news for hospitals and health plans and a frightening development for consumers, although not the really bad news some had feared. The President’s threat to let the insurance marketplace die and then “figure it out” sounds good as a rallying cry to the troops on social media, but is not the kind of thing that investors and CEOs like to hear.  Realistically though, at this point everybody knew that the uncertainty would likely continue through the year (best case) or a year or longer (worst case) as the gridlock in Washington plays out. As depressing and frustrating as it is that the uncertainty will continue, by this point the industry is used to it. Insiders will continue to look for ways to minimize risk and for business opportunities to capitalize on the uncertainty.

Trump’s plan to allow the insurance exchanges to collapse is the kind of confrontational talk Trump and his advisors relish. In theory, the idea could work. There are in fact signs that it already is, as major insurers leave the marketplace and consumers hesitate before committing to expensive insurance policies.  In reality, however, the collapsing exchanges will create a political crisis that is even worse than the current one for the administration, with news cycle after news cycle dominated by stories of terminally ill cancer patients and parents with children with horrible diseases and no insurance coverage. At this point, it will be difficult for the party doing the collapsing to point at the other side and say “It was them. They did it!”

Moderates see some sort of brilliantly crafted compromise as the obvious solution. In any place and time other than Washington in the year 2017 that would probably be the case. Unfortunately, despite what you’re hearing, it probably isn’t going to happen. Extremists on both sides are unlikely to accept anything less than complete and total victory.  With the President on hand to reliably blow up negotiations with ill considered tweets and taunts, all of the pieces are in place to ensure that the  healthcare reform story continues season after season.

If you are a person with a serious pre-existing condition or somebody facing a life threatening health condition, you can be forgiven for feeling extremely unwell right about now. Will you be able to pay for your drug prescriptions next year? Will you even be able to buy insurance coverage next year?  If you are able to buy insurance, will that insurance coverage be worth the paper it is printed on? If by some miracle, you are in fact able to buy insurance coverage, will some insane person take it away from you at some later date in time?

John Irvine is the editor of the Health Care Blog. He can be followed on Twitter at @thcbstaff. He can be reached by email at john@thehealthcareblog.com

By ADRIAN GROPPER, MD

The bipartisan 21st Century Cures Act charges HHS / ONC to deal with two issues that previous laws (HIPAA and HITECH) and the Obama HHS left in-progress: information blocking and longitudinal health records. ONC needs to deal with these two issues at a time when there are calls to delay or rescind some Meaningful Use regulations, in an administration that does not favor regulations, with some vendors already starting to ship Meaningful Use Stage 3 EHR products, and while the budget for ONC is still undetermined. ONC can’t be too careful.

Judging by the agenda, the July 24 21st Century Cures Act Trusted Exchange and Common Agreement (TFCA) Kick-Off Meeting is a step in the wrong direction. Listening to the “health IT stakeholders” is a prescription for advancing the interests of the health IT stakeholders instead of dealing with patients and physicians as the stakeholders. Framing the issue as “National Trust Frameworks and Network-to-Network Connectivity” is a recipe for continued ineffective interoperability as the “stakeholders” line up for another round of regulations that promote rent-seeking middlemen with catchy names like Direct Trust, and CommonWell.

National trust frameworks work when the institutions being trusted are fairly uniform, like the banks participating in money transfers or police searching law-enforcement databases. But healthcare institutions are way more diverse than banks or police departments. Some, like a psychiatrist’s practice or a small group are hardly institutions at all. Patient-centered care means networking institutions as diverse as a mom-and-pop long-term-care facility and the massive VA hospital and Medicare bureaucracy. Patient-centered care must support family caregivers like me, trying to keep my 91-year-old mom from becoming somebody’s procedure. Patient-centered care means we have a plan for longitudinal health records as an outcome rather than attempting to regulate technological process like “network-to-network connectivity”.

“National Trust Frameworks and Network-to-Network Connectivity” for the first high-profile ONC meeting is a framing that continues the failed policies that brought us state health information exchanges, DirectTrust, and other uninvited middlemen to the physician-patient relationship.

Interoperability and longitudinal health records are an outcome sought by physicians and patients. When a patient says to a provider: “Please allow X to access all or part of my record via the Meaningful Use API until I say otherwise”, the patient is exercising a fundamental right regardless of who or what X is. (API =Application Programming Interface) There is no role for a trust framework in patient-directed exchange. There is no need for coercive patient identity matching in patient-directed exchange. There is effectively no cost to the patient in patient-directed exchange via API. There is no legal basis for information blocking in patient-directed exchange via API. Just like a patient giving a provider a postal address to send records to, it just works, and the provider doesn’t get to say: “I don’t trust that address, so I’m blocking this request.”

Longitudinal health records are enabled by patient-directed exchange because the patient is able to tell any of her providers: “Let X access my health record.”, where X is a longitudinal health record service that the patient has chosen. X could be a primary care doctor, a web service, or even an artificial intelligence like IBM Watson. Various doctors, service providers, and institutions could decide for themselves whether to access a longitudinal health record at X and if they decided that they don’t want to use X the patient might go elsewhere. This is no different than a merchant deciding to accept American Express or ApplePay. They have a right to decline the customer’s choice but they risk the customer going to another provider if they do.

But is there a need for interoperability that is not directed by the patient? Surely it’s convenient if a doctor can just ask around for who might have records about a patient without bothering the patient to remember them all. This is similar to what police do when they stop your car. They ask you for some identifying information and go poke around various databases to see who might have some information about you. Police access the various databases on the basis of their role whether you like it or not. The police don’t tell you where they are accessing your information and they don’t need your permission to access it. The police and the databases they are allowed to access are part of a trust framework. It’s more or less a national trust framework. It’s definitely useful. It’s also coercive. It also means that people might not trust the police, a problem that police often cite with regard to serving undocumented people. There’s that patient ID thing again.

Medicine is not law enforcement and caregivers are not the police. Assembling large databases of patient records and then managing access on the basis of trust frameworks creates an illusion of interoperability, as nationalized health systems like the UK NHS have shown. It may seem more efficient than asking the patient: “Where can I find your health records?” but it’s bound to fail because the participants in medical interoperability are much more diverse than police.

If not a police analogy, then maybe the trusted intermediaries are like the three credit bureaus that help merchants figure out where a person has credit relationships without asking the person to list their current relationships. That’s a good model for driving interoperability toward a valued outcome (credit) and a good consumer experience (don’t ask me for a list of all my relevant accounts). Merchants are supposed to ask for permission before requesting your credit report from a very limited number, three, of regulated intermediaries. But there’s no trust framework like the mythical one in healthcare because the merchants don’t get to take that credit report and ask the various banks and other merchants listed for more details about you without explicit and separate authorization, for example, auto-pay. So yes, there are reasons to introduce trusted and regulated intermediaries into the interoperability solution but they need to be in the service of a specified outcome, like credit, and the person still gets to decide if the merchant-to-merchant link is authorized, like auto-pay, on a case-by case basis regardless of any trust framework.

It’s time for ONC to treat patients and their caregivers as the primary stakeholders in health information interoperability. Let’s focus the new ONC on patient experience and outcome. Trust frameworks are not a solution to either information blocking or longitudinal health records. The July 24 meeting could be a good place to start but I don’t see either patients or physician advocates on the agenda – just would-be middlemen looking for regulatory capture.

 

By ROSS KOPPEL and JASMINE MARTINEZ

Ending healthcare for those who need it will not make them or their problems disappear. On the contrary, the GOP plan will shatter American families and the economy. Nothing magical happens if we stop caring for the elderly, the ones who need vaccinations, the small infections that can be treated for $2 worth of antibiotics, the uncontrolled diabetics, and those with contagious diseases who clean our schools’ offices and homes. They don’t just get healthy.

As George Orwell said in Down and Out in Paris and London, “the more one pays for food, the more sweat and spittle one is obliged to eat with it.” Cutting care only exacerbates illnesses, infection, disability, the effects of age and the costs to society. The burdens continue or increase but the cost is shifted to American families, businesses, and states.

Fifteen years ago, one of the authors showed that lost productivity from workers caring for Alzheimer’s patients cost US businesses over $60 billion a year. Employee-caregivers, usually at the peak of their responsibilities and corporate experience, quit, prematurely retired, were constantly distracted, or engaged in presentism (e.g., at work but focused on mom burning down the house). Business cost were incurred by the need to replace workers, extra training of replacement workers, and increased pressure on other workers to cover for caregivers. The more expensive the employee, the longer and more costly the search and the longer the time to get them up to speed. But that study examined just a miniscule number of patients and workers compared to the tens of millions of people affected by the proposed GOP bill. As noted, it’s not only those needing care, but our society and our families that must deal with the elderly, ill, disabled, under and uninsured, children not receiving even ordinary care, people not being screened for preventable illness, and countless others.

Extrapolating from Koppel’s tiny study to the US population and businesses reveals the GOP bill will cost the nation trillions of dollars in losses and extra costs. It will devastate state budgets, and explains why GOP governors are among those leading the resistance.   Consider these facts:

• Most every nursing homes (SNF— Skilled Nursing Facilities) depend heavily on Medicaid, the program that will face the largest cuts by all of the GOP plans. What will happen to the millions of our elderly, disabled, and infirm? The lawns and parks of Washington DC and the 50 state capitals could hold only about 5% of them, where, of course, they would die without care.
• 75 million Veterans receive care via Medicaid. In fact, less than half receive care via the VA health system because some don’t qualify for various reasons or live too far from a VA facility to for primary care.  Many vets instead rely on Medicaid. Over thirty states and the District of Columbia chose to expand Medicaid to cover more people — especially veterans.
• Ironically, while President Trump campaigned on a pledge to force lower drug prices, the GOP plan gives greater freedom to drug companies to set prices. Freeing the FDA to accept less rigorous clinical trials on medications and medical devices is supposed to lower costs. Drug and device companies will be given greater latitude to define “proxy end points,” a term that means they don’t have to really show the drugs’ or devices’ long term effects, e.g., if a drug is shown to shrink cancer tumors after, say, 2 months, the company need not continue the trial for another 9 months—where there’s a good chance it might show the tumors return, or the drug fails, or that the drug or device harms patients through other means. More directly, getting products to market with less testing does not lower the prices of drugs that have been on the market for years and are now being up-priced by a few thousand percent—which is the case with many of the recent pricing scandals. In fact, the GOP committees on drug pricing just cancelled hearings.
• Hospitals and medical schools depend on many of the programs cut by the GOP plan. The Association of American Medical Colleges(AAMC) “predicts that the United States will face a shortage of between 40,800-104,900 physicians by 2030.”   Cutting training and research dollars will not increase the number of doctors or the good they can accomplish. While about 5,000 doctors offer concierge medical care for fewer than one million family members of multimillionaires, that will leave the remaining 319,000,000 of us scrambling for care. Googling “WebMD” is not a substitute for health professionals.
• This GOP bill forged a rare unity among medical societies, addiction physicians, hospital associations, nursing homes, and almost anyone else involved with healthcare. In contrast, big Pharma and the medical device companies win regulatory freedoms and tax cuts. They seem less hostile to the bill.
• Not providing birth control will mean millions of more abortions and unwanted babies. Those children born will not disappear, but rather will need care to become productive members of society. This is an additional burden on the American public and taxpayers.
• The largest growth area in the US labor force was and is healthcare. There are about 13 million healthcare workers in the USA, of which about 3 million are nurses, 800,000 are physicians, the rest are pharmacists, technicians, respiratory therapists, nurses’ aides, etc. In contrast, there are only about 15,900 miners in the entire USA who are involved with extraction, mining machine operations or earth drillings. Mining jobs have declined for decades because of extraction technology (e.g., mountain top mining and bigger drilling machines), natural gas, pollution concerns, etc. In contrast, even in mining communities, it’s often healthcare jobs that are available. Cutting healthcare jobs is a surefire way to increase unemployment. It will destroy entire communities. Even West Virginia has about 81,000 healthcare workers whereas it has only a few thousand active miners.
• Finally, returning to the costs borne by businesses and society: People denied healthcare are more likely to need caregivers. In 2015, the average age for caregivers was about 49 years old, 85% of which provided care for a relative. 60% of caregivers were employed within the last year while they provided care to someone, while 56% of them worked an average of 34.7 hours per work. 43.5 million adults “provided unpaid care to an adult or a child.” Many caregivers are still at an age where they must work, are forced to make accommodation with their jobs, and their extra labor receives no monetary compensation.

• The caregiver role is seldom short-term: “three in five care recipients have a long-term physical condition (59%), more than a third have a short-term physical condition (35%), and a quarter have a memory problem (26%).” The unforeseeable end to their role as a caregiver creates a twofold effect on them as their labor remains unaccounted for in the GDP. Unpaid family caregiving costs the nation approximately $470 billion in 2013. For Walmart alone (not exactly the company with the highest paid workforce) the economic value estimate totals more $477 billion.

Offering poorly designed or no health insurance to Americans will not make their problems disappear. Instead, we are left with more costly health problems. Sicker Americans, in addition to paying incomprehensibly large medical bills, will be forced to exit the workforce early–increasing financial burdens on business and families.

Perhaps most important, the GOP plan copies Obamacare in not really confronting healthcare prices. Instead, it only denies insurance, allowing largely unchecked the dizzying array of prices. As Bret Stephens writes, the same blood test in California can vary from $10 to $10,169; a lower back MRI in the USA can range from $199 to $6,221. A more dramatic comparison is the cost of care in the US vs. other nations, where US costs are usually 3 to 5 times higher. In the US, average angioplasty prices are $31,620, whereas in the UK, they are $7,264.

The CBO looked at the loss of insurance and the transfer of wealth to the super rich–both staggering. Yes, there were some deficit reductions from denying healthcare to millions. As we try to show here, however, even those “savings” will backfire horribly for the American government, our citizens and our economy. Neither we nor the CBO address the inhumanity implicit in the proposal health plans. For that there are other metrics.

Ross Koppel is a professor at the University of Pennsylvania. Yasmine Martinez is a senior at Vassar College.

By SAURABH JHA, MD

An old disagreement between Uwe Reinhardt and Sally Pipes in Forbes is a teachable moment. There’s a dearth of confrontational debates in health policy and education is worse off for it.

Crux of the issue is the more efficient system: employer-sponsored insurance (ESI) or Medicaid. Sally Pipes, president of the market-leaning Pacific Research Institute, believes it is ESI. Employers spend 60% less than the government, per person: $3,430 versus $9,130, per person (according to the American Health Policy Institute). Seems like a no brainer.

Pipes credits “consumerist and market-friendly approaches to health insurance” for the efficiencies. She blames “fraud,” “improper payment,” and “waste” for problems in government-run components of health care.

But Uwe Reinhardt, economist at Princeton, counters that Medicaid appears inefficient because of the risk composition of its enrollees. Put simply, Medicaid recipients are sicker. Sicker patients use more health care resources. Econ 101.

The points of tension in their disagreement are instructive.

Is ESI free market?

The term “consumerist” instinctively appeals to competition and choice, elements we value in free market. However, health care can’t be compared to shopping for single malt in airport duty free, deciding between Talisker 18 and Glenlivet 21.

ESI is hardly an assortment of private units functioning autonomously and competing with each other. ESI has been carved by so many regulations that the government figuratively runs through its veins.

Do you wonder why insurers in ESI don’t surcharge a family with a child with Tetralogy of Fallot? That is increase their premiums astronomically or deny coverage because of a pre-existing condition.

Goodness of heart? No, it’s because of the government.

This means that young fit joggers are subsidizing the costs for the unfortunate child’s complex cardiac surgery. Insurance is redistribution.

Risk adjustment: Comparing apples and oranges

Failure to adjust for comorbidities makes it difficult to make comparisons in quality, value and performance.

Not only are Medicaid enrollees sicker, they are poorer and less empowered. A priori they are a more inefficient group to deal with than the employed middle class.

I’ll hazard a guess that Sovaldi (medication for hepatitis C) won’t increase Microsoft’s health care bill as much as the state of Illinois’. One, of course, would not credit Microsoft’s cost savings to greater efficiency through clever free market insurance design.

However, in policy discussions comparisons between apples and oranges are commonplace.  Life expectancy and infant mortality are used to compare U.S. health care to countries such as Cuba or France, when adjudicators well know, or should know, that there is more nuance. Using metrics which can be affected by social determinants of health is misleading.

Is Medicaid an island?

There are no islands in health care.

It’s important not to make the same logical errors with Medicaid as with ESI.  Medicaid is not an autonomous government unit. Its recipients aren’t sent solely to safety net hospitals. For most parts Medicaid recipients share the same system as folks on ESI; a system which, arguably, has been sculpted by ESI, for better or worse.

This means there’s interdependence between ESI and Medicaid, or between a government-regulated/ government-subsidized system and a government-regulated/ government-funded system.

Interdependence would be suggested by cost shifting, where costs of seeing Medicaid patients are shifted to ESI. Even if there is no convincing evidence of cost shifting, as Reinhardt cautions but Pipes disagrees with the caution, this interdependence is not diminished. Providers, or hospitals, might happily see Medicaid patients knowing they can still enjoy good returns from ESI, without purposely shifting costs to ESI, or other forms of insurance.

Politics, Ideology and Medicaid

Medicaid is more than a system of reimbursing physicians. It has become an ideology. Any criticism of Medicaid leads to the unfortunate conclusion by some well-intentioned individuals that the purpose of critique is to send the poor to workhouses and let them die – de facto eugenics. No rational discussion can be had when people shout “Republican reforms kill.” The mob clouded the judgment of Pontius Pilate – and that was before Twitter.

Good intention does not mean access, though. Medicaid recipients have a problem of access. This is because Medicaid pays providers far too little whilst simultaneously imposing far too much red tape. Poor access is fiercely countered by some policy analysts and their fierce counter is fiercely countered by practicing doctors who actually see patients on Medicaid.

Regardless, paying providers the least when caring for the sickest, poorest and most disenfranchised section of society does no favors to that section of society.

Medicaid pays a cardiologist, with years of training, $25-40 for a consultation to manage a complex patient with multiple comorbidities, on polypharmacy, where the cardiologist must indulge in shared decision making and also ensure the patient adheres to statins.

For comparison, my personal trainer charges me $80. There’s no shared decision making – he tells me to do “burpees” and I must abide or face his wrath.

Serve and volley at the margins

Both Reinhardt and Pipes cite several studies supporting their point of view. One wonders whether policy wonks truly can form opinions solely from evidence since it’s so easy to cite evidence to support one’s prior convictions and subconsciously disregard or criticize the methodology of studies which refute our convictions.

For example, outcomes are often used to adjudicate the efficacy of treatments and healthcare systems, and the same constituency which flags poor outcomes when comparing the US healthcare to Sweden’s asks that these outcomes not be used to assess the efficacy of Medicaid. I agree with them as strongly as I disagreed with their use of life expectancy to judge American healthcare.

Disagreements are common because economics is not a hard science such as physics. It does not so much get us to the objective truth as it does to the action at the margins through methodology that is not as robust as the physical sciences, yielding different results on different occasions.

Who is correct, Reinhardt or Pipes?

In a sense both.

Reinhardt is right. Medicaid recipients are not the same as those enjoying ESI.

Pipes is right. Medicaid has structural issues. It pays physicians too little compared to ESI.

This begs the question which reimbursement corresponds to the fair market price in health care: Medicaid or ESI. We will never know because health care has not operated as a free market, and never will. And ESI does distort the price signals as do mandates and virtually everything else.

But here is the important point: ESI is going nowhere. Neither the most left-leaning Democrat nor the most right-leaning Republican has the courage to rid health care of ESI.

What’s the objective truth? Which system really is more efficient?

The truth lies in the answer to this: Would ESI deliver the level of care enjoyed by ESI recipients with paucity of cost sharing that Medicaid recipients face to Medicaid enrollees at a lower cost than Medicaid?

For Medicaid recipients cost sharing should be zero otherwise it defeats the purpose of a safety net. But remember we want them to have the same level of care as ESI for a true apples-apples comparison.

It’s practically impossible to conduct a randomized controlled trial to answer this question. Nor does empiricism suffice. All quantitative analyses have assumptions. With regards to assumptions I can do no better than paraphrase Groucho Marx: “Those are my assumptions, and if you don’t like them … well I have others.”

Importance of disagreements

The current system does not have many genuine alternatives. Single-payer is out as is a genuine free market. As politicians don’t wish to talk about costs because of political expediency, all we are arguing about is which part of health care has the most administrative cost/ informational loss. This is at best a marginal argument. To resolve this argument I would encourage more dialectic between partial truths.

But if Medicaid truly is a high risk pool, and I believe it is, then it should be treated as the other high risk pool – Medicare. Which means that the poor and sick, the uninsurable, should be covered by the Federal government through general taxation. I would suggest a “Medicare for the Poor” which offers the same benefits as traditional Medicare. This would allow the states to balance their budgets better and concentrate on local infrastructure, such as parks, police and public libraries.

Summary of key points

1. It’s more cost-efficient treating healthier patients.
2. Accurate adjustment for comorbidities and social determinants of health is key for any comparisons in health care. This is (never) seldom achieved.
3. There’s interdependence between employer-sponsored insurance and Medicaid.
4. No one knows true market prices in health care because it’s not a free market.
5. Economic analysis yields information about the margins, until the next analysis.
6. The poor should be covered by the Federal government through general taxation.

About the Author:

Saurabh Jha is a contributing editor to THCB. He can be reached on Twitter @RogueRad

 

 

 

By RICHARD GUNDERMAN, MD and BENJAMIN GRAY, MD

Many physicians have expressed dismay at the conduct of US president Donald Trump.  But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times.  In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message.  McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey.  To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated.  As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19^th century debate audiences expected candidates to develop real arguments for their policies.  As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites.  In fact, McLuhan argued that the medium of television operates “at the speed of light.”  It permits “no continuity” and “no connection.”  Instead, he said, with television, “It’s all just a surprise.”   In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

Those baffled at Trump’s trajectory must concede that he has mastered the media of our age, especially television.  He became a national media phenomenon largely through his role on “The Apprentice,” where he starred between 2004 and 2015, and from which he boasted that he had earned $214 million.  It has also been widely reported that Trump relies far more than any of his predecessors on television as his principal window on the world.

McLuhan predicted that television would breed a culture of spontaneity and impatience.  He likened the situation to the left and right hemispheres of the brain.  The left expects everything to be “connected, logical, and goal-oriented.”  But the ascendancy of television brings a shift to the right, which makes “the old left hemisphere world, which is our educational and political establishment, look very foolish.” 

A television president might look foolish to the traditional educational and political establishment, but he might also make those establishments appear foolish to a television-saturated public.  The modus operandi of such a president would be not reasoned argument, for which the medium of television has little tolerance, but the creation of associations, in much the same way that an advertiser might brand products.

Statecraft Becomes Show Business

This point was amplified by another media theorist, Neil Postman, who contended that television is a supremely visual medium that rejects ideas.  In his 1985 book Amusing Ourselves to Death, Postman argued that “It is in the nature of the medium that it must suppress the content of ideas to accommodate the requirements of visual interest; that is to say, to accommodate the values of show business.”

In effect, Postman carries McLuhan’s central point even further, arguing that the medium becomes not just the message but our “dominant means for construing, understanding, and testing reality.”  Recognizing that appealing to the emotions of the television audience is far more important than any rational argument, and that the medium is suited to nothing better than entertainment, a television president would naturally emphasize show over substance.

What would a generation of viewers – or even a second or third generation – reared on television expect from its president?  To answer such a question, we need but imagine a person who has read little but watched a million television commercials.  Such a person, Postman wrote, would “expect political problems to have fast solutions through simple measures,” and would think that “complex language is not to be trusted” and that “all problems lend themselves to theatrical expression.” 

Twitter Becomes Twaddle

These liabilities are only amplified when we consider what would likely constitute an entertainment president’s preferred medium for messaging: Twitter.  With a 140-character limit on tweets, such messaging richly rewards the ability to further simplify the message, placing an even greater premium on what entertains, or even better, outrages.  The goal is not so much to inform or persuade but to grab and keep tight hold of the public’s attention, at which Trump has exceled.

At the core of McLuhan’s and Postman’s critiques lies a charge of immaturity that could also be leveled at a Twitter presidency.  Both men died before Twitter was invented, but they would likely echo journalist Clive Thompson’s 2008 assessment that the new medium has elevated narcissism to “a new, super-metabolic extreme – the ultimate expression of a generation of celebrity-addled youths who believe their every utterance is fascinating and ought to be shared with the world.” 

No one can predict with certainty the ultimate verdict of history on the entertainment presidency.  We can, however, characterize with great confidence the irresistible effect of contemporary mass media on the messages transmitted to us through political discourse.  Some people hate Donald Trump.  Others love him.  But all health professionals can agree that he has high entertainment value, and given the media that dominate our age, such a presidency is all but inevitable.