Friday, October 7, 2016

The Latest Health Wonk Review is Up

That's right, Paduda's Pre-election pundit ponderings is now present for your perusal and learning pleasure.

Friday, September 30, 2016


According to this BloombergTechnology report, "some" customers of health insurer Aetna will get a discount on Apple's smartwatch. In the meantime, Aetna's employees will get the watch at "no cost" to " beta test a new wellness reimbursement program."

While media reports imply that this is one more step toward a Manifest Destiny of scaling healthful behaviors to lower U.S. healthcare costs, the Population Health Blog is more sanguine:

1. The impact of wellness programs - exercise promotion, healthy eating and lifestyle management - on short term health insurance claims expense is highly variable.  There's lots of peer reviewed literature like this that shows "fitness" is not a healthcare money-saving slam dunk.

2. In addition, wellness programs are far more likely to be successful if they are tailored, multi-modal and sustained over time. Kudos to Aetna, which linked the smartwatch to a broader employee wellness program that probably meets that gold standard.  As for the "other customers," the PHB doubts that the one-time provision of a wrist gadget will do anything to mitigate their healthcare costs.

3. It is the conceit of today's Silicon Valley Robber Barons to think that no problem is immune to their business models. Just like Carnegie and Rockefeller, the Gates and Zuckerbergs seem to believe that but for (their) information technology, the world could be a better place.  Apple's executives can't be blamed for its "features to help our customers live a healthy life" hype.

4. But even if some of Apple's executives are immune to the hype, their marketing department undoubtedly understands that "cause related" appeals to societal fitness builds brand. Plus, if the earned media helps deflect attention away from Apple's lackluster stock price and Aetna's other travails, all the better.

5. It's difficult to know for sure, but the PHB doubts that Aetna is deploying any of its customers' premium to underwrite their cost for the Apple smartwatches.  Rather, this is far more likely to be a group purchasing discount in which Apple agrees to less margin in exchange for a bulk purchase.  That's probably also part of the math for the Aetna employees, with the rest of the economics of the wellness program simply being part of Aetna's administrative overhead.  

Nonetheless, the PHB is intrigued by the downstream possibilities of a Wintel-like alliance between a major commercial health insurer and a major information technology company.  What's described above is small potatoes compared to the larger possibilities of data sharing*, big-data analytics, co-branding, mutual investments, joint ventures and administrative combinations.

Think Aepple.  You read it here first.
*After this post was published, this news report came out.

Tuesday, August 23, 2016

When Diet Meets Technology

This is a post authored by the folks at ph360. The Population Health Blog was intrigued by the innovative combination of personalized dietary wellness management, evidence-based medicine, consumerism, artificial intelligence and a digital concierge.

Discoveries in biology, genetics, epigenetics, biotypology, and medicine are revealing that the best approach to being healthy and staying that way is to have a diet that is right for your body (1). What works for an “average” person may – or may not - be optimum for you.

So how do you know what’s right for you?

Welcome to the future of healthcare, where mHealth diet applications will come to the rescue. While today’s apps are rudimentary and require a lot of manual input, technology advances are making dietary apps highly advanced, automated and tailored.

The ideal app of the future will reconcile individual human physiology, and its adaptation to changes in environment and lifestyle, to provide more complete, detailed and personalized recommendations for staying well and reaching health goals (2).

Emerging technology will combine algorithms that calculate the risk of disease, monitor current lifestyle habits and health trends, and predict a future trajectory with recommendations of best practices for disease prevention or management. Genetic and phenotypic factors will be used to calculate health risks, and identify trends to provide tailored protocols. Wearable technology will monitor and signal important biological functions, and the continuous data collection will increase computer learning that further refines the technology. New discoveries will automatically update these systems so that users feel more confident and minimize faddism.

Though it seems like all of this is far into the future, it’s actually not. Sophisticated applications that consider a holistic approach to preventative medicine through such technology are already emerging.

Enter Shae

Matt Riemann, suffered from a rare genetic condition called Familial Amyloid Polyneuropathy.  This causes nerve dysfunction and has a life expectancy of approximately 10 years after onset.

In the course of collaborating with many specialists, scientists, geneticists and others, Matt not only overcame his condition but created ph360. With the premise that each person is unique, the ph360 platform guides a personalized approach to dietary health.

ph360 was launched two years ago, and after accounting for body measurements, genetic data, health history, and lifestyle, aggregates 10,000 data points and more than 500 ratios to recommend personalized food, fitness and lifestyle changes that achieve optimal health.

The Details

Shae, is built on the ph360 program.

First, body shape and structure are measured to gain insight on morphology, biotypology, and genetics. Research in epigenetics, for instance, has found that height is associated with cardiovascular conditions (3), digestive health (4) and even cancer (5). Waist circumference is related to cardiovascular risk (6) and diabetes (7). Various body ratios, such as height to weight, have been medically associated with increased risk of osteoporosis (8), certain metabolic conditions (9) and important hormone levels (10).

Health surveys are also used to get a better gauge of health risks. For example, skin and hair color is associated with the risk of sun damage (11), nail structure can indicate mineral deficiencies (12), and lifestyle choices can increase or decrease the likelihood of disease onset or progression (13, 14). Chronobiology (15) and the natural human aging process are considered (16) to provide insights on how sleep and stress affect health and well being (17) or how health risks may increase or change with age (18).

Shae takes ph360’s insights one step further by providing 24-7 support for ph360 users as a “Virtual Health Assistant.”  It’s being engineered to use interactive voice and text conversations to communicate a personalized health plan with users in real time via their phone, tablet, laptop or smartwatch. Shae will connect with wearables and analyze a user’s data to make practical recommendations regarding diet, exercise, and lifestyle activities that directly influence their health.
Following users through their day and responding as circumstances – such as environment, activity, diet and stress levels change, these are some of the things that Shae will communicate:

Recommended specific foods ideal for the person, indicate why and provide nutrient information, recipes and shopping lists for the recommended foods that the user selects.
Recommended the very best exercises for the individual’s fitness goals and specific body type, the ideal time of day to exercise and best sports to play.
How to integrate Geomedicine through GPS, making recommendations for foods, activities, transportation and more based on where the person is in the world.
How to optimize your schedule based on body rhythm to help minimize stress and increase productivity.

Shae has been funded on Kickstarter and is currently being funded on Indiegogo. Version 1.0 will be available in October 2016.  Upgrade versions will be released every few months with version 1.5 arriving in July 2017.  The upgrades are all covered in the original purchase price.


1. Ferguson, L. R., et al. "Guide and Position of the International Society of Nutrigenetics/Nutrigenomics on Personalised Nutrition." Journal of Nutrigenetics and Nutrigenomics 9.1 (2016): 12-27.

2. Ferguson, Lynnette R., ed. Nutrigenomics and nutrigenetics in functional foods and personalized nutrition. CRC Press, 2013.

3. Lee, Crystal Man Ying, et al. "Adult height and the risks of cardiovascular disease and major causes of death in the Asia-Pacific region: 21 000 deaths in 510 000 men and women." International Journal of Epidemiology (2009): dyp150.

4. Asao K, Kao WH, Baptiste-Roberts K, et al. Short stature and the risk of adiposity, insulin resistance, and type 2 diabetes in middle age: the Third National Health and Nutrition Examination Survey (NHANES III), 1988–1994. Diabetes Care 2006;29:1632–7.

5. Kabat, Geoffrey C., H. Dean Hosgood III, and Thomas E. Rohan. "Adult Height in Relation to the Incidence of Cancer at Different Anatomic Sites: the Epidemiology of a Challenging Association." Current Nutrition Reports 5.1 (2016): 18-28.

6. Nazare, Julie-Anne, et al. "Usefulness of measuring both body mass index and waist circumference for the estimation of visceral adiposity and related cardiometabolic risk profile (from the INSPIRE ME IAA study)." The American Journal of Cardiology 115.3 (2015): 307-315.

7. Chamnan, Parinya, Hansa Choenchoopon, and Suvit Rojanasaksothorn. "Abstract MP93: Waist Circumference Has a Stronger Association With Diabetes Than Body Mass Index: Results From a Large Health Examination of 355,310 Thai Men and Women." Circulation 131.Suppl 1 (2015): AMP93-AMP93.

8. Asomaning, Kofi, et al. "The association between body mass index and osteoporosis in patients referred for a bone mineral density examination." Journal of Women's Health 15.9 (2006): 1028-1034.

9. Jacobsson, J. A., et al. "Genetic variants near the MGAT1 gene are associated with body weight, BMI and fatty acid metabolism among adults and children." International Journal of Obesity 36.1 (2012): 119-129.

10. Osuna C, J. A., et al. "Relationship between BMI, total testosterone, sex hormone-binding-globulin, leptin, insulin and insulin resistance in obese men." Archives of Andrology 52.5 (2006): 355-361.

11. Veierød, Marit Bragelien, et al. "Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi." Cancer Epidemiology Biomarkers & Prevention 19.1 (2010): 111-120.
12. Cashman, Michael W., and Steven Brett Sloan. "Nutrition and nail disease." Clinics in Dermatology 28.4 (2010): 420-425.

13. Roberts, Christian K., and R. James Barnard. "Effects of exercise and diet on chronic disease."  Journal of Applied Physiology 98.1 (2005): 3-30.

14. Moritani, Toshio. "The Role of Exercise and Nutrition in Lifestyle-Related Disease." Physical Activity, Exercise, Sedentary Behavior and Health. Springer Japan, 2015. 237-249.

15. Lloyd, David, and Ernest L. Rossi, eds. Ultradian rhythms in life processes: An inquiry into fundamental principles of chronobiology and psychobiology. Springer Science & Business Media, 2012.

16. Lin, Jue, Elissa Epel, and Elizabeth Blackburn. "Telomeres and lifestyle factors: roles in cellular aging." Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis 730.1 (2012): 85-89.

17. Mullan, Barbara A. "Sleep, stress and health: A commentary." Stress and Health 30.5 (2014): 433-435.

18. Singh, Gitanjali M., et al. "The age-specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: a pooled analysis."PloS One 8.7 (2013): e65174.

Thursday, August 18, 2016

The Health Wonk Review

Check out this Health Wonk Review post by Healthcare Economist blogger Jason Shafrin.  There's something for everyone: health insurance, mental health, pharmaceuticals, regulations, privacy, return on investment, value-based care and more!

Friday, August 12, 2016

The Lament About the Healthcare "Return on Investment"

The Population Health Blog had time to go back and review this New England Journal article on "return on investment" in healthcare

It's abbreviated "ROI."

In it, academic researchers David Asch, Mark Pauly and Ralph Muller lament that interest in getting a "return" from reducing healthcare utilization is unfair. While it is a sought-after metric in chronic conditions (for e.g., diabetes) it's practically unheard of other care settings (for e.g., cancer care).

The authors point out that may be because:

1) Care of conditions like cancer is very remunerative to providers, so there is little interest in reducing income. In contrast, diabetes has little "top-line" potential;

2) Unlike conditions like diabetes, reimbursement around the "episode of care" following a new diagnosis of cancer explicitly supports a known - and profitable - suite of hospital-clinic services;

3) "Savings" from reduced health care utilization can be complicated by the "back-filling" of empty appointment slots and unfilled beds with other patients with other needs and other sources of income.

There are two solutions.

The first is at the front-end by decreasing (with or without bundling) the reimbursement. That would presumably force the providers to gain care efficiencies that exceed the accompanying lower payments.

The second is at the back-end with "shared savings." This financially rewards providers who can muster efficient episodes of care. In other words, the check is the "ROI."

All good points, but written from the provider perspective.  From the perspective of buyers (businesses and individuals who buy/pay taxes for commercial or government insurance) it's more simple: services flex up to meet generous fee schedules and flex down when payment shrinks.

The right balance between the money and care can be determined by brutal and efficient markets or by all wise and mistake-prone policymakers.  Take your pick, implies the authors, but if it's the latter, the results are preordained.

The PHB would offer three other points on ROI:

1) We've seen this movie before: Using financial incentives to drive fewer hospitalizations, drugs and specialists is perilously close to rewarding the withholding of needed care.

2) Measuring non-events is hard: "ROI" in most healthcare settings is not a classic ratio of income to investment, but savings to investment to savings. The latter is ultimately based on a statistical measure of what doesn't happen vs. the baseline utilization of a large population. It's not easy to discern the "signal" of fewer pricey hospitalizations, fewer expensive drugs, or less need to see costly specialist physicians from the "noise" of healthcare inflation.

3) High health status ≠ low cost: Increasing quality of life is often a function of increased access to costly health care that is often a function of socioeconomic status.  In other words, you get what you pay for in both healthcare and lifestyle.

Which is the PHB's lament It's not a function of "saving" money, but using it wisely.  It's not a matter of ROI, but creating patient-centric value.

Image from Wikipedia

Tuesday, July 12, 2016

President Obama Writes About Health Care Reform in JAMA

All aboard!
In a first for the Journal of the American Medical Association ("JAMA"), President Obama has authored a Special Communication on "United States Health Care Reform."

As the Population Health Blog would expect of any modern sitting President's essay on any political achievement, there are no new insights, no new useful lessons learned and no regrets. The reader is instead treated to an Affordable Care Act (ACA) legacy-building "bus tour" of selected facts and gratuitous framing of the Affordable Care Act (ACA). a

Briefly, Mr. Obama points out that, thanks to the ACA, the national uninsured rate dropped by 7% from 16% to 9%, which was accompanied by a 3.5% increase in the number of individuals with a personal physician and 2.4% increase in access to medicine. He takes credit for declines in the inflation rate for health care spending, decreases in consumer out-of-pocket health care spending, the rise of value based care, and improvements in quality of care.

The President goes on to putter around the edges with some suggestions for "building on progress to date":
He closes with "lessons for policymakers":
  • While change is difficult, "hyperpartisanship" makes it doubly so. The tools of hyperpartisan sabotage include "inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation."
  • Special interests "like the pharmaceutical industry" still "pose a continued obstacle to change."
  • The ACA is an example of American middle ground pragmatism between the extremes of vouchers for all and single payer. It should continue.
The PHB's Take

As years of over-lawyering has taught Americans (indeed, JAMA has put the academic credential "JD" after Barack Obama's name), real peer-reviewed policymaking benefits not only from the truth, but the whole truth.

What makes this JAMA piece less than the whole truth is failure to mention (other than in passing) how lingering of the Great Recession is what blunted the majority health care inflation, that a shocking amount of treasure as well as political capital was used for a seemingly modest 7% absolute reduction in the uninsured rate, that government sponsored plans will likely put the remaining regional insurers out of business, and that the prospect that any company doing business in the U.S. being legally compelled to share proprietary cost information is highly unlikely.

Oh, and by the way, short of firing up some more money-printing presses or some real reforms, Uncle Sam has no money to pay for any of the additional proposed suggested goodies.  There is no political appetite for shoveling any more federal money toward health care.  

Last but not least, the ACA was midwifed by a hyperpartisan ramrod that failed to get even one Republican vote in either chamber of Congress. This Special Communication does nothing to diminish that legacy.
Was this a squandered opportunity to set the record straight and address some meaningful reforms?

You be the judge.

But don't take the PHB's word it. Appearing in the same issue of JAMA is this editorial by the Brooking Institution's Stuart Butler.  He points out that Medicaid and not the marketplaces was responsible for a significant majority of newly insured Americans, that, even with premium support (or its expansion), commercial insurance enrollees are now saddled with very high out-of-pocket costs.

Oh, and then there is a consensus - now that the Recession is waning and the ACA is taking hold - that health care inflation is poised to accelerate.

Image from Wikipedia

(Updated July 14)

Tuesday, June 21, 2016

Problem-Based Wisdom, The Age of Em, Reputation Economics and End of Life Care

The Population Health Blog has been busy with building on the value proposition of IT-enabled care management, helping to plan a 2017 trade show agenda, training for a race, learning about cyber-security, and staying out of the way of the PHB spouse as she plans two family weddings.
But that doesn't mean it hasn't been thinking 'bout a lot of stuff. Namely:

End-of-life care: A non-physician colleague asked the PHB why the U.S. can't seem to mitigate the skyrocketing costs of futile treatments for persons who are dying. The PHB's response was that patients and their families are less interested in value than they are in hope, and that "futility" is often discernible in hindsight, not in an ICU at 2 A.M. In addition, as "bundled payments" gain traction, patients and families may have to again wonder about the impact of local economic conflicts of interest. The PHB thinks this will get worse before it gets better.  It wonders if part of the answer may lie in Shared Decision Making, in which an independently derived calculation of the odds of survival with and without disability is provided to patients and families, along with the space to decide next steps.  Think less "defined benefit" and more healthcare financing.

An Interesting Book: Reputation Economics by Joshua Klein builds on the observation that humans ultimately prefer to trade goods with persons they genuinely trust. The invention of money as a medium of exchange may have solved a lot of inconveniences, but it also distanced the seller and the buyer. He suggests that our Information Age is ironically ushering in a return of barter, where many goods and services can be directly exchanged between parties who create a track record of their trustworthiness online. Interestingly, your personal identity doesn't need to be part of that reputation. And if barter isn't available, enter cryptocurrency like Bitcoin, which preserves anonymity but commands trust.

Another Interesting Book: The Age of Em by Robin Hanson suggests that there is less to traditional machine-based artificial intelligence than meets the eye, and that it will be simpler within the next century to image and build a replica (or "emulation") of a human brain. As a result, these super-devices will be capable of self-learning, handle all tasks and oversee a rapidly expanding economy that has little need for (real) humans. If this book is true, the PHB's current and future grandchildren can look forward to a lifetime of pure leisure.  Maybe they can spend part of that time reading PHB's past posts.....

A hot-off-the-presses PHB peer-reviewed publication: This examines how healthcare institutions' boards of directors can leverage the wisdom of crowds, problem-based learning and non-linear generative governance to create insights and unlock competitive value. Traditional governance with fiduciary and strategic oversight is unequal to the task of thriving in a complex and rapidly changing healthcare marketplace. "Problem-based wisdom" occurs when boards step back and ask more questions and seek more options. You can read the paper here.

Friday, June 17, 2016

The Latest Health Wonk Review is Up!

Practically nothing goes unexamined in the latest Health Wonk Review, which is hosted by the Health Affairs Blog.  Chris Fleming does a superb job of summarizing and linking the latest smart bloggery on insurance, healthcare reform, costs, wearables, artificial intelligence, pharma, guidelines, risk adjustment, cancer funding and workers' comp.  Oh, and Theranos too.

Tuesday, June 7, 2016

The Latest Health Wonk Review Is Up

The latest Health Wonk Review is bustin' out and up at David Harlow's erudite HealthBlawg. Dance on over to the latest insights of the top health policy bloggers here

Wednesday, May 25, 2016

Pricing, Product and Audience: Theranos and DTC Blood Testing

Is the Population Health Blog due for a meal of humble pie?

In this prior post, the PHB was "long" on Theranos' prospects.  Since that was written, Medicare has alleged that a company lab was a "jeopardy to patient health and safety," a peer-reviewed study showed troubling test inaccuracies, the Securities and Exchange Commission (SEC) has opened an investigation, higher ups have left the company, years of test results have been "voided"  and founder Elizabeth Holmes faces the prospect of a ban from doing business with Medicare and Medicaid. And to add injury to insult, Walgreens has bailed out.

In this well-written Viewpoint published in JAMA, Stanford's John Ionnidis composes a Theranos requiem that ultimately questions the virtues of the company's low-cost and direct-to-consumer blood testing. He argues that while the solution of self-diagnosis and early treatment only sounds revolutionary. That pales in comparison to the far larger problem of misdiagnosis that leads to the reality of overtreatment.

Good point.  But, while Theranos' prospects are clouded, the PHB is still long on the underlying three point business model.  Theranos got one right, and the other two are within reach.

To wit,

1) The pricing is uncoupled from opaque insurer-based fee schedules and based on rational consumer-driven price points.

2) The product is health insights, not blood testing data.

3) The audience of buyers/regulators need to understand the value-based outcomes  
The PHB explains:

1) Theranos stumbles over internal quality control and regulatory compliance issues will play out, and, after a sufficient number of heads roll, will be addressed.  Once that's settled, consumer interest in being able to circumvent insurance and "buy" transparently-priced and OTC blood tests should remain considerable. Medicare's fee schedules are ultimately "cost-plus" which includes the costs of a highly inefficient care system. Think about that $500 stitch and it's little wonder why consumers are so willing to forego the sticker-shock and co-pay hassles to beat a retail path to Theranos' door.

2) Consumer insights about screening blood tests come from combining the test results with pre-test odds, sensitivity and specificity.  While a smart physician can certainly help patients navigate an abnormal liver function test or a high cholesterol, distance technology combined with consumer-friendly machine intelligence (here's a simple example) can also. It's simply a matter of industrializing and democratizing what we've known for decades. And once consumers can understand tests' imperfections, things will rationally equilibrate between under and overtreatment

3) For many reasons, healthcare is a different business. Among the many reasons for that is that "success" is particularly dependent on the need to understand the short and long term outcomes and costs (i.e. value) of any new care model. That means committing considerable resources to study, document, internalize and publicly report what was achieved at what price. An audience of scientists, regulators, providers, insurers, buyers, politicians, physicians and bloggers want to know: does open-range testing for Hepatitis C paired with education on true and false positive test results reduce the incidence and costs of cirrhosis or liver cancer?  Does consumer self-ordering blood glucose levels combined with post-test odds reporting increase awareness of otherwise undiagnosed diabetes and increase claims expense? Does DTC pregnancy testing.... oh, wait, we know that one. You get the picture.
If not Theranos, then some other company will profit from putting patients in at the center of lab testing.  The genie is out of the bottle.

Since first posted on May 25, there have been update modifications.