Wednesday, August 4, 2010

An Air Travel Themed Health Wonk Review: Frequent Flyer Miles For Your Brain

Welcome to this airline travel version of the Health Wonk Review. Why such a theme, you ask? Well, it is my blog, but, to be honest, the Disease Management Care Blog has been preoccupied lately by achieving an "Up In The Air-esque" Premier Executive frequent flyer status. That can make all the difference between no leg room and a few precious inches, the back vs. the front of the plane and no hope vs. some hope of an upgrade.

This wonky review is no different: thanks to the contribution of numerous bloggers, readers will get miles of insight into the latest developments in health care policy.

Quick introduction: the Disease Management Care Blog writes about disease management, the medical home, case management, wellness, managed care, health insurance and federal legislation, with an opinionated emphasis on science and published evidence. Glad you came to visit and please, stop by again.

So, let's head for the airport in this merry wonky travel adventure!

First off, isn't air travel such a hassle? Between the expense, the lines, the scanners, the waits, the cancellations, don't you just wish you could find a cheaper alternative? While airlines may start making seats optional, a more friendly health care alternative, says David Williams, is increasingly becoming available. Called "MinuteClinics," these care centers seem to offer comparable medical expertise, shorter wait times and lower prices to an American public disenchanted with technology. Maybe the next option is to dispense with pilots.

The DMCB wonders about those metal detectors and the security check point. Is its face going through facial recognition? Has its hard drive been imaged? Has it been the subject of unflattering pics that are au naturel? The same level of intrusiveness is the topic of of the InsureBlog, who gave a test drive and found it to be disturbingly nosey and, compared to the web sites of private insurance agents, quite user unfriendly.

While you're waiting in line to board, did you ever look at your ticket? No, the DMCB means really scrutinize it. All those numbers and other hieroglyphs are pregnant with meaning and, with time and effort, they can probably be deciphered. Over at the HealthAffairs Blog, Timothy Jost helps us interpret the ticket to coverage of pre-existing conditions in the Affordable Care Act. Now you know why that ticket may not quite be everything you thought it was.

Getting past the ticket agent to the jet bridge, it'd be easy to marvel at the confluence of technology, systems, capital, and human resources that will get you from Point A to Point B. Yet, the airlines keep saying they're losing money, that they need to merge, that we should trust that they won't act like monopolies and that they're playing nice with government. Beware, says DrRich of the Covert Rationing Blog, the same dynamic may be afoot in the health insurance industry, which has put the Obama Administration exactly where they want us. You can read all about it here.

Stepping on board, isn't amazing how the flight attendants can be so solicitous, smiling, friendly, polite and helpful? Well... the are most of the time and it's probably because they're trained to be that way. Why not use that approach in our nation's physician-training programs, asks Chris Langston over at the John Hartford Foundation Blog. Two weeks of an eldercare clerkship seemed to have a modest impact on medical students' attitudes toward geriatric patients: they seemed to not dislike them as much. Keep that in mind the next time you ask for a pillow, and the flight attendant grits her teeth, gives you a fake smile and murmurs "certainly."

Gotta get that overhead bin! Airlines seem to be charging for checked baggage, which has the side effect of making people scramble for that prized space for their carry-ons close to their seats. Yet, the DMCB wonders if there are fewer bins. The appearance versus the reality is also a topic of discussion over at the nothwithstandingblog, who thinks that there may be something to the notion that low fee Medicaid/S-CHIP fee schedules may have something to do with a possible shortage of pediatric specialists.

Settling into your seat, you may want to take a glance at that huge turbine engine and wonder if it's gotten sufficient maintenance. Good point, says Gary Anderberg over at Workers Comp Insider. Getting passengers safely to their destination isn't a matter of return on investment; getting employees to be healthier isn't either. It's a more fundamental question of risk management. The DMCB agrees and grimly buckles its seat belt.

While we're at it, wouldn't it be cool if air travel didn't have to depend on costly and dirty jet fuel? Travelers are probably vaguely aware of new technologies, but, alas, they are not even close to being ready for prime time. A similarly sorry state of affairs exists for Accountable Care Organizations (ACOs) says Brad Flansbaum. Sure, the concept may look promising, but there are a host of unanswered questions that need to be answered before we'll really know if it works. Now why isn't the chair recliner working?

Uh oh. Looks like the person on the next seat is already laying claim to the arm rest. Such a small thing, but there is nothing like hours of elbow dueling to make the flight interesting. Health Beat's Maggie Mahar gives the Cato Institute a hard progressive nudge when she points out that the original mandate was the Militia Acts of 1792, which required citizens to provide themselves with a musket. Even those wacky Tea Baggers may agree with that, but the DMCB likes this quote provided by Cato: "The left may ridicule the suits that have been brought against ObamaCare by more than 20 states and others, but in doing so they ridicule nothing less than the American heritage of limited constitutional government. If ObamaCare revives that heritage, it will all have been worth it."

Double uh oh. It appears the person on the next seat is a chatty cheery optimist also. The DMCB prefers to be left alone in silence with its biased notions, but that's not going to stop the bright Austin Frakt of the Incidental Economist Blog from pointing out that the individual mandate is working in Massachusetts because it is reducing adverse selection, only minimally increasing premiums, are aligned with the penalties which is good news for the rest of the country because there will be little gaming even though that may not work in other states its OK because there are tweaks possible. The DMCB is resisting putting in the ear phones because the guy may be right - as usual.

Are the earphones working? The DMCB likes that because it thinks the sound quality and the number and variety of in-flight tunes have increased lately. That's the ticket, says John Goodman over at the Health Policy Blog. He argues there's a direct inverse correlation between government/third party meddling and entrepreneurial health care innovation. Hm, says DMCB, it wonders if the lack of FAA regulations are responsible for that awful Lady Gaga tune. If so, it's going to hire a lobbyist: everyone else is, it seems.

Among the worse outcomes for the DMCB is getting stuck on the tarmac in a long aluminum tube and no idea when "wheels up" will happen. There are many reasons for delays: weather, flight patterns, safety considerations, regulations etc., but that doesn't mean clueless passengers haven't fantasized about going into the cockpit, grabbing the controls and taking off anyway. Deciding to use the emergency room has the same dysfunctional calculus for persons that are unable to understand what their symptoms mean, whether there are any other available providers and if waiting is an option. The problem, says Brad Wright of Wright on Health, is that there are emerging data showing that having insurance doesn't lessen reliance on emergency rooms, no more than having a ticket guarantees knowing what a Ground Stop means.

That doesn't mean the DMCB doesn't marvel when a multi-ton contraption filled with people finally does take off or that it doesn't feel some anxiety when the wings visibly wobble during flight. The cognitive dissonance that comes with being simultaneously safe and being tens of thousands feet in the air is not unlike the parallel realities of the States' implementing elements of the Affordable Care Act, says Joanne Kenen of the NewHealthDialogBlog. Sure, many are in active opposition but that doesn't mean that they aren't also going to comply, because that's what States ultimately do. The DMCB agrees, but sometime prefers to deal with the peculiar unrealities of flying with beverages that come in those small weenie bottle like containers. Like at least two of them.

Where is that beverage cart? As it slowly makes it way down the aisle, the DMCB is reminded of nurses using a drug cart and passing meds as they slowly make their way from patient room to patient room. While they're at it, there are other countless patient concerns, making it a full time job and a half. No wonder by the time they get to the DMCB 's seat they can be grumpy about that request for a second bag of pretzels. Well, in hospitals, they can be outright angry at the way these institutions expect them to do more and more for less and less. Case in point, courtesy of Gary Schwitzer's HealthNewsReview Blog is a narrowly averted nurse strike in Minnesota.

Maybe, thinks the DMCB, flight attendant to passenger staffing ratios need to be more intelligent. Factors such as age, prior flying experience and customer expectations could be used to flex on board staffing. After all, the idea has merit in healthcare, says the folks over at the INQRI Blog. Using an "acuity index" saves lives in neonatal intensive care units. Using a "don't you realize how important I think I am?" quotient on the DMCB may save it some inconvenience. Not.

Of course, knowing how much the executives earn at the top of the managerial pyramid isn't going to help make anyone feel better. Adding to the nurses' - and the passenger-patients' - dismay is this compelling review of the twisted logic and dysfunctional market dynamics that permit not-for profit hospital executives to be paid shocking amounts of money. Health Care Renewal points out that institutional size makes little difference, it seems, to the routine compensation that runs into the hundreds of thousands of dollars.

Speaking of dysfunction, Anthony Wright of the Health Access Blog thinks California's Anthem Blue Cross subscribers deserve better. Getting from here to there is not just a function of replacing the CEO, says he. With the exit of Leslie Margolis, hiring a new CEO should really be a first step the company's waking up to a new business model dedicated to serving its customers by competing on cost and quality.

That wouldn't be so bad if the expense resulted in a better, safer and ultimately cheaper flying experience. "Comparative effectiveness research" is supposed to accomplish much of the same thing, but beware says Rich Elmore, over at Healthcare Technology News. It can be overly scientific, dry and inconclusive. Like those $9 meals in a box. Unlike travelers, will taxpayers get what they pay for in CER? Stay tuned!

During the seat backs up, trays put away, stuff-under-the-seat or else landing, the DMCB is reminded that getting off the plane doesn't necessarily mean that it's arrived. There's transportation to the hotel for example. The same is true when it comes leaving acute care and having to deal with long term care insurance. Some passengers like to wing it when they disembark for nursing homes, but Jay of the Long Term Colorado Insider points out that you should plan for the $70,000 yearly cost as early as possible. Like before you even get on the plane.

Once on the ground, it's comforting top know that we have customer surveys, eh? The DMCB gets great satisfaction in filling them out after it flies, so take that and that. Hit "send" and..... what? The same "tastes great but isn't filling" let-down may be in store for patients that fill out those hospital quality surveys, points out the Healthcare Economist Blog. The data may be prone to manipulation because those collecting the information also happen to be responsible for assembling it, summarizing the results and interpreting it.

And don't forget that other statistical manipulation may be called for. The DMCB frequently flies through Chicago, and its learned that getting out on time may be a function of weather, not the airline. You can get a sense of just how important the methodology can be in this discussion by Avik Roy of whether an Annals of Surgery article on Medicaid vs. uninsurred mortality rates is telling the truth or whether there is a bias.

So, the DMCB would be the first to welcome you to the conclusion of the HWR. You may now turn on your cell phone, but it asks that you remain seated until your PC has pulled up to the gate and you've gotten some more work done.


H G Stern said...

Super job, Jaan!

Thanks for hosting, and for including our post.

BTW, where's the white ccourtesy phone?

Michelle W said...

Excellent HWR: I was able to get an idea of what each post was about, judge what I wanted to read, and felt my mood lighten at the same time. Brava.

INQRI Program said...

Great job hosting and thanks for including us!