Thursday, September 25, 2014

Dr. Emanuel Hopes He Dies Before He Gets Old

Poor judgment.

The Population Health Blog can't discern another explanation for Ezekiel Emanuel's Why I Hope to Die at 75 article in The Atlantic.  Since leaving Washington DC, Dr. Emanuel has become safely ensconced at the University of Pennsylvania, where he can disclose what he was really thinking while he was helping to stand up the Affordable Care Act.

The Population Health Blog appreciates Dr. Emanuel's recycled nostrums on the quality vs. quantity of elder-years, Americans' unrealistic yearnings for immortality and medical over-testing. And, if the essay prompts patients and families talk to their doctors about end-of-life care, even better.

But those good points are far outweighed by four intellectual blunders:

1) The watershed age of "75" that is used by Dr. Emanuel is an averageMany individual patients suffer declines in quality of living and life expectancy before as well as after that particular age. The PHB has been privileged to care for healthy persons aged 85 who have been correctly looking forward to additional years of rich and rewarding activity.

2) The "value" of a "poor quality" life is in the eye of the beholder. The PHB has also been privileged to care for very unhealthy persons over the age of 75 who remarkably treasure every day they are alive. Who is Dr. Emanuel to disagree with their decision-making?

3) While The Atlantic piece is about the writer's very personal views, they're not only arguably ageist, they're confirming the worst fears of the "death-panel" loonies.

4) Last but not least, real doctors know that healthcare preferences can change. That's especially true for end-of-life care, where yesterday's kitchen-table decisions routinely fail to account for today's emergency room realities. While Dr. Emanuel may hope he dies before he gets old, he should think on how the lyricists behind My Generation continue to rock decades later. He may live to regret his words.

Tuesday, September 23, 2014

The Antifragile VA: Lessons from the NFL

Unacceptable behavior. Tone deaf sanctions. Superficial investigations blaming a few bad apples. Contrite leadership promising change.

Population Health Blog readers might think that this is about the National Football League (NFL), but it's also about the Veterans Administration (VA) whitewash.

But, in reality, this is about something much bigger: the unpredictably predictable dysfunction that happens to large and complex organizations. Mix insular leadership (Commissioner or Secretary), an unaccountable bureaucracy (owners or appointees), huge budgets (as in very huge) with hidebound government oversight, and something very big and very bad is bound to happen. Sooner rather than later.

That something often remote (an elevator or a Phoenix clinic), is only obvious in retrospect (atrocious male violence or gaming outcomes), signals a deeper problem (player recruitment or leadership integrity) and results in a loss of reputation that lasts for years

Think baseball and steroids, NASA and shuttles, GM and starters, Presidents and red lines.

This is classic antifragility.  As we continue to concentrate economic and social power into large organizations, logarithmic jumps in complexity will lead to rare, contagious, catastrophic and unpredictable crack-ups. Naturally, our response will be to layer in more systems complexity.

Assuming large and complex ACOs prove they can really conjure money out of providing fewer health services, the PHB believes their next biggest threat is a black swan event. A huge patient data breach.  Withholding care.  Cutting corners.  Something else. You read it here first.

In the meantime, smart PHB readers will discern that there are some important differences between the NFL and the VA:

                                  VA                                            NFL
Problem:               Waiting lists.                      Switches and fists.

Involving:                   Docs                                     Jocks

Result:          Congressional indignation.       Sponsor consternation

Solution:             Budget Conference                    Press conference.

The Media:     Monday morning quarterbacking   Monday Night Football

So the chief gets:          Replaced                         Breathing space

The real problem:        A monopoly                         A monopoly

Tuesday, September 16, 2014

Telehealth Helps!

... and have you taken your pills today?
Are you in the "telehealth" business? 

Do you sell, buy, broker or provide remote monitoring, telephonic follow-up, internet-based patient management, handheld health apps, video-support or home-based medical devices? 

Then you'll probably want to download this 32 page paper.

Bashur and colleagues set out to review every good (defined as any controlled study with a valid concurrent comparison group with at least 150 study subjects) research paper on the impact of telehealth on three conditions: heart failure, stroke and chronic obstructive pulmonary disease.

177 references later, their conclusion is that telehealth - over a broad range of patient types (age, illness severity and co-morbidities), level and intensity of patient participation, provider types (nurses vs. physicians with or without an explicit protocol) - increases quality of care and reduces unnecessary utilization. 

In other words, telehealth is substitutive.  It doesn't add to inefficient services, it replaces them with something cheaper.

The Population Health Blog already knew that, of course, but it's handy to have an authoritative text that catalogs every published study.

What the PHB didn't quite know:

The official definition:

Telehealth (e-health, mobile health, m-health), connected health) is the delivery of healthcare via information and communication technology.

Telehealth jargon: when you launch it, make sure you have:

1. Fidelity (use in an appropriate setting with optimal strength and integrity),

2. Maturation (the technology may not have fully integrated personnel, other technology and patients to achieve maximum efficiency) and

3. Bundling (where the technology is vulnerable to how other concomitant supporting services are configured.

Monday, September 15, 2014

Is One DIet Program Better Than Another for Weight Loss?

As a doctor, the Population Health Blog was often asked by overnourished patients to help find a "best" diet.  Its advice to simply eat less and skip desert, however, was insufficient to overcome the commercial programs' allure of word-of-mouth, dubious advertising and fanciful on-line marketing . As a result, many desperate PHB patients fell into closed loops of pseudoscience, anecdotal testimonials and expertly crafted statements "not evaluated by the FDA."

As a population-health skeptic, the outcomes-focused PHB was never convinced that one commercial diet plan was "better" than any other.  Not only are excess calories very efficiently turned into corpulence by a very efficient human metabolism, it didn't make sense that that persons could eat their way to weight loss with more [insert one of the following: protein, fat, fiber, pre-packaged meals or vitamins].  Last but not least, if all these commercial weight loss outfits spent a tenth of their marketing budget on real science, the PHB may have had the evidence it needed to make a recommendation.

Well, a meta-analysis of "Named" (you'd recognize the brands) diet program outcomes has been published in JAMA and the results are decidedly unimpressive.  The good news is that all of the household-name programs result in modest weight loss compared to no diet.  The bad news is that the loss of two to six pounds for each program was no better or worse compared to the others.

The PHB's take?  It's up to the consumer to weigh their personal preferences for one type of diet plan vs. another.  In addition, out-of-pocket costs may also play a role in helping sustain the dieter's motivation in getting their money' worth. 

Beyond those two considerations, however, it's just a matter of eating less calories, not more of the latest nutritional fad.

Friday, September 12, 2014

Of Risk Stratification, Health System Variation and "Stupid" Decision-Making

A fly in the ointment
Years ago, a middle-aged Population Health Blog patient came in for a routine follow-up appointment.  Since his last visit, he had developed iron deficiency anemia. Since slow blood loss can be a sign of an early and curable cancer in the gastrointestinal tract, the PHB recommended a series of unpleasant tests. After a rather routine explanation of the time, expense and inconvenience of those tests, the patient surprised the PHB with a one-word answer: "No."

He went on to live for decades.

Which brings the PHB to this JAMA article on individually-tailored screening for another type of cancer. While even screening for prostate cancer is controversial, it's possible to stratify a man's risk of the condition with some questions, examination data and test results.  That risk can be portrayed in lay terms (there is a "42-in-100 chance" that cancer is present, but doing a biopsy has a "4-in-100 chance of causing an infection..."). 

The points of the well-written article is that 1) risk-stratification can be used to identify persons at high vs. low risk, 2) the decisions to screen, perform additional testing and embark on treatment can be, based on that risk, "tailored" to maximize a good outcome and 3) patients can use their level of risk to ultimately decide how they want testing and treatment to achieve the outcome they want.

Bravo, says the PHB.  While we're on the cusp of understanding whether a more sophisticated approach to screening ultimately leads to better outcomes than the standard all-or-none guideline (USPSTF "recommends against prostate-specific antigen (PSA)-based screening for prostate cancer"), there is enough face-validity to believe that patients will ultimately benefit.

But there is a fly in the ointment and a monkey in this wrench.

The fly? Variation will not go away. While health system bureaucrats everywhere would prefer that 0% of men undergo prostate screening, that 100% women over 50 get mammograms, and that 0% of us have a body mass index in excess of 25, individuals - after looking as the risk-benefit here, here and here, may choose otherwise.  We don't know what the "right" screening rates are.  In fact, we may not be asking the right questions.

The monkey?  Some "bad" decisions will occur. Once persons truly understand the benefits, risks and alternatives (including not dying prematurely of a preventable illness and side-effect risks that are less than driving in a car), they are allowed to make "stupid" decisions.  Physicians and bureaucrats may not like it when anemic patients, like the one described above, refuse no-brainer recommendations, but in a free country that's the price we pay. Our challenge is to make sure that our patients have all the information they need (which is apparently not the case here) to make a truly informed decision.

Image from Wikipedia

Thursday, September 11, 2014

The Latest Health Wonk Review Is Up!

Are you proud to be a "wonk?"  Well, you can burnish your wonky credentials by clicking here and checking out David Williams' latest edition of the Health Wonk Review. You can learn about using the Medicare fee schedule to rationalize pricing, bundled payment, old problems and new proposals for U.S. healthcare reform, the VA and much, much more.

Tuesday, September 9, 2014

Is the United States the Only Country Into "Patient Engagement?" (plus a definition)

Patient engagement is there too!
The answer is no.  Check out this paper in Health Affairs that defines patient engagement as ordinary people who manage their own health by shifting the clinical paradigm from determining “what is the matter?” to discovering “what matters to me?” 

The authors point out that patient engagement is a phenomenon in Great Britain, the United Arab Emirates, India and the United States:

England's "Big White Wall" is an online community accessible via handhelds or computers where persons with psychological distress can find support in managing their care.  Participation is anonymous and is covered (£100 for 6 months) by some of the local National Health Service organizations or by employers directly. There are questionnaires, guided support programs, moderated discussion groups and individual 'live" therapy (£75 per session). Supporters point to data that suggests there are fewer physician visits that result in a net savings.

The United Arab Emirates' pattern of tribal consanguinity has led to a high incidence of inherited genetic disease. In response, the UAE recruited and paid student "ambassadors" to lecture about genetic screening among the country's university student population. That plus mandated screening plus coverage of the cost has led to an increased tribal acceptance of screening for thalassemia and sickle cell disease.

In India, a checklist was promoted and given to new mothers to help them spot danger signs in their babies within a week of birth. The checklist was loaded on the mom's cell phones, which was sent prompts about looking for problems, such as breathing difficulty or poor feeding. If there was an "yes" answer to any question on the list, the health system was alerted.

In the U.S., Boston's Deaconess Hospital identified a hundred patient and family "advisors" who sit on ten committees and give input into various quality improvement projects in the institution.  This has facilitated the ability of patients and families to view their test results on line, get prescription refills or trigger an inpatient concern.

Thursday, September 4, 2014

Underwriting vs. Care Management

Rock on, care management
In the course of learning about care management, the Population Health Blog has benefitted from sitting at the feet of high-functioning finance experts, actuaries and underwriters. Reconciling health care revenue/expense, trend, monetized risk and pricing of insurance with the savings, quality and patient experience that comes from optimized care has been a fascinating - if sometimes frustrating - intellectual exercise.

However, this report on the rise of machines and the continuing displacement of knowledge workers reminded the PHB of the divide between the science and the art in this corner of health care. 

According to David Autor, it's only a matter of time until machines begin to displace the high-end brainiacs who oversee the health insurance industry's premium, reserves, claims payments and surpluses.  Human judgment will never go away, but logarithmic jumps in processing power combined with the big data that comes from industry consolidation means the "answer" on how much to charge for coverage of a person with diabetes will be less flexible and more preordained.

The PHB, however, is of good cheer. 

While underwriting risk will be all about the numbers, managing conditions within those numbers will remain a very individual enterprise. Human needs, preferences, tolerances and culture will continue to shape highly variable decision-making within the care system for years to come. The need for highly skilled knowledge workers who can help patients co-manage their care will grow, not diminish. 

Factory farms may be churning out ingredients on an massive scale, but someone has to plate the finished meal. 

The music industry may be selling Beyonce at $0.99 a pop, but nothing will replace seeing her live in concert.

Payers and buyers may commoditize cataract care, but someone has to make sure patients take their eye drops.

Underwriting on one side.  Care management on the other.  The PHB likes where it's at.  

Image from Wikipedia

Tuesday, September 2, 2014

The Growing Parallels Between Health Care and Power Utilities

In some of its past musings, the Population Health Blog drew parallels between the airline industry and health care. While it knows nothing about aviation, who cares? It figures all those pundit MBAs and lawyers know nothing about medicine either: such is the standard of today's commentariat.

It knows nothing about power utilities either, but the gullible PHB sees parallels there too.  According to this Dummies chapter, utilities sell a heavily regulated commodity that requires a lot of debt-financed infrastructure. Since their customers have no where else to go, poor/low cost service can translate into it being considered a safe investment. Yet, do-it-yourself renewable energy is a growing threat. As companies go, they are not known for growth; rather they preserve capital and return profits to their investors in the form of dividends. And regulators are forcing these companies to reward customers for using less of what they're selling.

And what's the growing resemblance to health care? 

In their attack on variation, many services are being commoditized into a race to the bottom by payers and government.  Regulation is increasing. Poor/low cost service for "captive" patients can also mean greater profits.  The importance of access to capital, servicing debt and achieving savings are eclipsing top line revenue. Instead of dividends, they're "returning" surplus to the community in the form of more services. Do-it-yourself health care in the form of medical tourism, concierge physicians is a growing threat. And the system is starting to see incentives that help its customers to use less of what it's selling.

Is the PHB being naïve? You be the judge.

Monday, August 25, 2014

CMS Succumbs to Disease Management Style Spin?

If, thanks to the medical home or disease management, you've witnessed the improvements in patients' care, you've also probably been frustrated by those silly skeptics' insistence on validation. But for traditional research designs, statistical significance, valid comparators and publication in obscure scientific journals, the face validity of nurse-led care management for high risk patients could have ushered in a new era in primary care.

Darn those academic-actuary-statistician-weenies! And double darn CMS for falling for them and not funding the medical home and disease management!

Which is why Population Health Blog readers may enjoy this bit of peer-review schadenfreude. It appears a recent CMS pronouncement that its own "Partnership for Patients Program" prevented early elective deliveries and reduced readmissions is highly suspect, thanks to "a weak design, a lack of valid metrics, and a lack of external peer review for its evaluation." 


It appears the amateurs at CMS used a pre-post design, selected start and stop evaluation points to gin up the outcomes, relied on imperfect administrative data and never bothered with having its outcomes validated by independent review. As a result, we really don't know if the billion of dollars that went into PPP did any good at all.

The PHB appreciates the point. Scientific discipline and peer review go a long way making sure that consumers are getting their money's worth. Now that CMS has gone from an agnostic payer to the centerpiece of health reform, there's a huge risk that its bureaucrats will succumb to shortcuts and spin.

Taxpayers deserve better.  And so do patients.

Image from Wikipedia