tag:blogger.com,1999:blog-91818107256964099532024-03-17T04:20:11.156-04:00The Population Health BlogA contrarian, brainy and literature-based resource by Jaan Sidorov that offers jargon-free information, insights, peer-review links and musings from the world of population health, disease management, the medical home, the chronic care model, accountable care organizations, the patient centered medical home, informatics, pay for performance, primary care, chronic illness and health insuranceJaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.comBlogger1904125tag:blogger.com,1999:blog-9181810725696409953.post-69918068155768269362019-01-31T05:56:00.002-05:002019-01-31T05:57:56.267-05:00The Cure for Checkbox Medicine: Physician-Led Clinically Integrated Networks<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjT6M2WKolNr6TqvWoJZTXpX99g-q8ObAb0h2FXsam0ONWaVE0ds_bLdB9z5rQ4PUpko42aqQVBX4DF1YmosldlfzTKSQtWbA1OPdfY6Wo9juaysRWcnICiY_XdRrHpXRD_6nlDIQHoZRY/s1600/Compliant.PNG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="525" data-original-width="555" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjT6M2WKolNr6TqvWoJZTXpX99g-q8ObAb0h2FXsam0ONWaVE0ds_bLdB9z5rQ4PUpko42aqQVBX4DF1YmosldlfzTKSQtWbA1OPdfY6Wo9juaysRWcnICiY_XdRrHpXRD_6nlDIQHoZRY/s200/Compliant.PNG" width="200" /></a>Years ago, I was contacted by a health plan about an elderly nursing home patient who had not been screened for osteoporosis.<br />
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<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839837/" rel="nofollow noopener" target="_blank">While brittle bones are a big problem in skilled nursing settings</a>, the real problem for this health plan was its low <a href="https://healthpayerintelligence.com/news/how-hedis-cms-star-ratings-cqms-impact-healthcare-payers" rel="nofollow noopener" target="_blank"><u>HEDIS</u></a> score for “<a href="https://www.ncqa.org/hedis/measures/osteoporosis-testing-and-management-in-older-women/" rel="nofollow noopener" target="_blank"><u>osteoporosis testing and management</u></a>.” Because of the underlying <a href="https://www.youtube.com/watch?v=ztZLYIbQK88" target="_blank"><u>financial stakes</u></a> and the <a href="https://healthpayerintelligence.com/news/why-hedis-quality-measures-matter-for-value-based-care" rel="nofollow noopener" target="_blank"><u>marketing advantages</u></a> that come from claiming a “number one” spot in quality, the health plan nurse wanted me to order an “osteoporosis screening test.”<br />
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This is a classic example of <a href="https://www.nytimes.com/2009/11/17/health/17case.html" rel="nofollow noopener" target="_blank"><u>checkbox medicine</u></a> run amok. It their zeal to promote health care quality, payers, regulators, politicians and academics have meddled in the doctor-patient relationship with requirements promoted by HEDIS, the <a href="https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx" rel="nofollow noopener" target="_blank"><u>Stars Program</u></a>, <a href="https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html" rel="nofollow noopener" target="_blank"><u>MACRA</u></a> and other “<a href="https://www.ncqa.org/hedis/" rel="nofollow noopener" target="_blank"><u>performance assessment tools</u></a>” that are <a href="http://www.annfammed.org/content/15/2/175.full" rel="nofollow noopener" target="_blank"><u>often disconnected from the complexities of real-world care</u></a>. In the instance of the patient above, she had already been diagnosed with the condition (so no screening was necessary) and she had <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110860/" rel="nofollow noopener" target="_blank"><u>multiple contraindications to treatment</u></a>.<br />
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This made little difference to the health plan, which had created an entire department dedicated to tracking down every <a href="https://www.springbuk.com/what-is-gap-in-care/" rel="nofollow noopener" target="_blank"><u>care gap</u></a>. As their complexity and numbers grow, physicians are being hassled with quality metrics that are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4945566/" rel="nofollow noopener" target="_blank"><u>process-based</u></a>, <a href="https://news.aamc.org/patient-care/article/cms-star-ratings-criticism-academic-med-community/" rel="nofollow noopener" target="_blank"><u>statistically suspect</u></a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4648519/" rel="nofollow noopener" target="_blank"><u>non-transparent</u></a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765897/" rel="nofollow noopener" target="_blank"><u>burdensome to report</u></a> and <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1511701?page=0" rel="nofollow noopener" target="_blank"><u>of questionable value to patients or society</u></a>. This is not just a distraction, <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.1258" rel="nofollow noopener" target="_blank"><u>but a huge cost to physicians and ultimately their patients</u></a>.<br />
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Fortunately, there is an innovative cure for this problem. <a href="https://www.physicianleaders.org/news/what-clinically-integrated-networks-offer-physicians" rel="nofollow noopener" target="_blank"><u>Physician-led clinically integrated networks</u></a> (“CINs”) are <a href="https://www.mdedge.com/familypracticenews/article/142735/business-medicine/clinically-integrated-networks-5-roadblocks-and" rel="nofollow noopener" target="_blank"><u>safe harbors</u></a> for quality programming that are an alternative to checkbox craziness. These types of CINs are created to engage in <a href="https://catalyst.nejm.org/what-is-value-based-healthcare/" rel="nofollow noopener" target="_blank"><u>value-based care arrangements</u></a> with insurers; <a href="https://catalyst.nejm.org/value-based-compensation-rewarding-outcomes/" rel="nofollow noopener" target="_blank"><u>these “VBC” compensation models are gradually replacing standard fee-for-service</u></a> and are an important opportunity for any physician who has been struggling with check-box health care:<br />
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1. Physician-led CINs can negotiate terms that transfer ultimate responsibility for quality metrics from the “payer” to the “provider.” As these CINs develop their own workflows and hire their own personnel, physician oversight makes it far less likely that a colleague will be hounded by a well-meaning if clueless quality improvement nurse.<br />
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2. Physician-led-quality programs are not configured specifically for HEDIS but are likely to benefit HEDIS. In other words, as a CIN creates the policies, procedures, metrics, workflows, reporting and feedback loops for the management of chronic conditions, that rising quality tide will also benefit the HEDIS boat, and their measures will increase. It's care, not care gaps.<br />
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3. Health plans are burdened by dozens of quality measures imposed by employers and government, which, unfortunately, results in everything being so important that nothing is important. Physicians understand the virtues of setting priorities. When this is combined with their awareness of what matters most to their patients, CINs can negotiate limitations on the number of quality metrics. What can follow is real improvement.<br />
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4. Finally, while HEDIS and similar programs have been carefully developed over the years by considerable numbers of experts, health care quality is a rapidly moving target. Physician-led CINs can partner with enterprising health insurers and employers to rapidly develop and deploy new quality metrics using a classic “plan-do-study-act” (or <a href="https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b.html" rel="nofollow noopener" target="_blank"><u>PDSA</u></a>) approach. One area of opportunity is in the area of <a href="https://populationhealthalliance.org/wp-content/uploads/2018/07/PHA-Social-Determinants-Brief-July-2018.pdf" rel="nofollow noopener" target="_blank">social determinants of health</a>.<br />
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Many of my physician colleagues love to hate their insurers’ quality programs. Many will continue to write <a href="https://www.kevinmd.com/blog/2018/10/clicking-checkboxes-doesnt-meaningfully-improve-care.html" rel="nofollow noopener" target="_blank"><u>understandably angry editorials</u></a> or <a href="https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-what-we-lose-with-data-driven-medicine.html" rel="nofollow noopener" target="_blank"><u>compelling narratives</u></a> or stirring resolutions (<a href="https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/hod/a18-resolutions.pdf" rel="nofollow noopener" target="_blank"><u>see 108</u></a>) or public calls to <a href="https://www.kevinmd.com/blog/2016/04/physicians-patients-must-retake-control-health-care-delivered.html" rel="nofollow noopener" target="_blank"><u>just say no</u></a>.<br />
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Unfortunately, despite their many limitations, quality programs like HEDIS as well as value-based care are <a href="https://www.healthcatalyst.com/will-new-policies-impact-value-based-healthcare" rel="nofollow noopener" target="_blank"><u>here to stay</u></a> and has <a href="https://www.healthaffairs.org/do/10.1377/hblog20170518.060168/full/" rel="nofollow noopener" target="_blank"><u>overwhelming bipartisan support</u></a>. Fortunately, physician-led CINs using the four innovative approaches above offer a far more viable alternative. It’s up to physicians to seize that opportunity.<br />
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<em>This post was originally published on </em><a href="https://www.kevinmd.com/blog/2019/01/are-clinically-integrated-networks-a-cure-for-checkbox-medicine.html" rel="nofollow noopener" target="_blank"><em>KevinMD</em></a><em> of MEDPAGE; the blog is social media's leading physician voice. </em><a href="https://www.linkedin.com/in/jaan-sidorov-md-a164164/" target="_blank"><em><u>Jaan Sidorov</u></em></a><em> is an internal medicine physician and CEO and president of the </em><a href="http://www.patientccc.com/" rel="nofollow noopener" target="_blank"><em>Care Centered Collaborative at the Pennsylvania Medical Society</em></a><em>. The opinions expressed above are solely my own and do not express the view or opinions of The Collaborative or of The Pennsylvania Medical Society. However, hundreds of Pennsylvania physicians like the idea.</em>Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-3940809297278358282019-01-03T06:56:00.001-05:002019-01-03T06:56:42.832-05:00Ten Contrarian Predictions for Healthcare in 2019<br />
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<span style="font-family: "calibri";"><em>The Disease Management Care Blog resurfaces momentarily to repost a "Ten Healthcare Predictions for 2019" post from LinkedIn. The busy DMCB is CEO of <a href="http://www.patientccc.com/" target="_blank">The Care Centered Collaborative at the Pennsylvania Medical Society</a> and the thoughts below do not express the views of The Collaborative or of The Society. </em></span><br />
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<span style="font-family: "calibri";"><em>They do reflect a belief in physician leadership.</em></span><br />
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<span style="font-family: "calibri";"><strong>1. 2019 Will Be the Year of the Doctor<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">After a spending years in the health reform wilderness as <a href="https://www.kevinmd.com/blog/2012/04/implications-provider-doctor.html" target="_blank">commoditized “providers,”</a> doctors will reassert their hard-earned professional designation. <span style="mso-spacerun: yes;"> </span>Large health systems will see an uptick in
<a href="http://www.medicaleconomics.com/business/who-do-patients-really-need-physicians-or-administrators" target="_blank">physician-administrator tensions</a>, physician-owned entities that honor the
profession will have less trouble poaching talent and the ratio of employed to independent
physicians will stabilize.<span style="mso-spacerun: yes;"> </span>Contrary to
expectations, independent physician entities will cater to millennial doctors’ underappreciated
skepticism about corporate healthcare.<o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>2. Physician-led CINs – Health Information Technology
Reaches Critical Mass<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">As their fee-for-service (“volume”) income wanes and
payments are shifted to reward quality (”value”) the independent physicians
take advantage of advances in information technology to organize into clinically
integrated networks (CINs). <span style="mso-spacerun: yes;"> </span>Declining
costs and increasing sophistication of these information systems is lowering
the barriers to market entry. This will enable the best of both worlds: local independence
and regional interdependence.<span style="mso-spacerun: yes;"> </span>These entrepreneurial
doctors will be <a href="http://www.patientccc.com/cin" target="_blank">the surprise alternative to health system consolidation, hospital market dominance and one-size-fits all approaches to care</a>. Financial savings from other group purchasing arrangements
will be icing on this cake.<o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>3. From Revenue Centers to Cost Centers – The Emperor Begins
to Lose His Clothes<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">As hospitals scramble to get even bigger by buying one
another, constructing new wings and launching slick branding campaigns, these
glass and steel behemoths will begin to contrast with unflattering local
stories about inability of patients to get a timely appointment and a
convenient care plan. These noisy patients will use more social media to point
out something that elected officials, regulators and academics are missing:
that these complex mega-health care organizations cost more than they give.
Unfortunately, this alone won’t be enough to lead to change, but.....</span><br />
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<span style="font-family: "calibri";"><strong>4.<span style="mso-spacerun: yes;"> </span>Unholy Alliances –
It’s What Lies Under the Emperors’ Clothing</strong> <o:p></o:p></span></div>
<span style="font-family: "calibri";"><a href="https://www.wsj.com/articles/behind-your-rising-health-care-bills-secret-hospital-deals-that-squelch-competition-1537281963" target="_blank">The Wall Street Journal confirmed what many physicians suspected about hospital-insurer collusion</a>. 2019 will show how prevalent this
is: enterprising local reporters will find that their health system has been
using its local market dominance to dictate terms to health insurers.<span style="mso-spacerun: yes;"> </span>No longer just a matter of fat fee schedules
and lavish quality bonuses, terms of these contracts will leak and inform local
markets, showing anti-steering clauses, secretive pricing arrangements, extra
fees and the exclusion of lower-cost alternatives.<span style="mso-spacerun: yes;"> </span>As news of these arrangements spreads, embarrassed
health insurers will pull back from these agreements and look for network
alternatives.<span style="mso-spacerun: yes;"> </span>Combined with #2 above,
patients will be willing switch to these alternatives and large health systems
will begin to see declines in the rate of increase in their outpatient revenue.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>5. Risk Transfer Transfers Gain Pace<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">Health insurers are ultimately in the business of “risk
transfer,” in which the potential cost of a future healthcare event is accepted
in exchange for money. <span style="mso-spacerun: yes;"> </span>This monetized
risk <a href="https://www.managedhealthcareexecutive.com/technology/experts-share-how-apply-big-data-patient-care" target="_blank">increasingly being sliced, sorted, allocated and re-transferred</a>. While
this innovative area of insurance has been dominated by large systems,
increasing actuarial sophistication and growing risk appetite of smaller networks
– including physician CINs - <span style="mso-spacerun: yes;"> </span>will lead
to limited and profitable risk transfer arrangements. <o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>6.<span style="mso-spacerun: yes;"> </span>Social
determinants of health – Accountability is incomplete without fixing them.<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">As risk transfers to providers grow, awareness of underlying
socioeconomic threats to patient claims expenses will evolve in a Stages of
Change arc <a href="https://www.evidenceaction.org/blog-full/reflections-from-a-ghc-fellow" target="_blank">from “precontemplation” in 2018 to “action” in 2019</a>. An impatient
mandate to <a href="https://www.ajmc.com/newsroom/physicians-call-for-action-on-social-determinants-of-health" target="_blank">“do something!” </a>to manage social determinants will prompt frontline
healthcare workers will begin to use some of the upfront premium revenue from
their risk arrangements to mitigate the impact of determinants, such as poor
social supports, low education, and insufficient income. Unencumbered by an
insurer mindset, there will be investments in community-based supports, patient
education and non-medical services. <o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>7. More Venture Capital<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">The allure of artificial intelligence, connected health,
the human genome, block chain, consumerism, making the inefficient
more efficient and more <a href="https://www.economist.com/finance-and-economics/2018/07/26/private-equity-is-piling-into-health-care" target="_blank">will drive another run at finding “The Innovation” thatwill finally transform healthcare</a>.<span style="mso-spacerun: yes;"> </span>Alas,
this is less a function of the potential of market change than the lack of
investment opportunities elsewhere.<span style="mso-spacerun: yes;"> </span>Good
luck!<o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>8. All Eyes on Medicaid<span style="mso-spacerun: yes;">
</span></strong><o:p></o:p></span></div>
<span style="font-family: "calibri";"><a href="https://innovation.cms.gov/initiatives/state-innovations/" target="_blank">An accommodating posture in CMMS</a> will enable the leadership
of state Medicaid programs – and their managed care insurance partners – to
innovate.<span style="mso-spacerun: yes;"> </span>One area ripe for change are
quality metrics, which have been dominated by entities such as the NCQA, NQF
and AHRQ. Criticized for being disconnected from what patients really value,
state Medicaid Directors will show a willingness to adopt new measures and
reward health systems that can move these new needles. <span style="mso-spacerun: yes;"> </span>Physician-led CINs will lead the way and
they’ll start by arguing that a number one priority should be measures of social
determinants of health.<span style="mso-spacerun: yes;"> </span>By the way,
venture capitalists (see 7 above) will miss this bus.<o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>9 The JPMorgan- Amazon-Berkshire Thingy Will Go Nowhere.<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">Didn’t these companies’ ERISA plans already exploit the low
hanging fruit?<span style="mso-spacerun: yes;"> </span>Between Warren Buffet’s hardnosed
actuaries, blockchain’s unreadiness for prime time, the limits of Alexa-style healthcare
consumerism, and Atul Gawande being the Peter Principle personified, this
three-way alliance will remain stuck in countless video conference rooms in
Seattle, New York City and Omaha.<o:p></o:p></span><br />
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<span style="font-family: "calibri";"><strong>10. Medicare for All Takes Off<o:p></o:p></strong></span></div>
<span style="font-family: "calibri";">The Donald will demonstrate once again that he has no
ideological moorings, no respect for fiscal responsibility and no embarrassment
from co-opting his opponents’ ideas. Once the fight over The Wall has been
squeezed for every possible advantage, the President will shamelessly signal
he’s open to a version of “Medicare for All.”<span style="mso-spacerun: yes;">
</span>Why not?<span style="mso-spacerun: yes;"> </span>Insurers will see
opportunity in the expansion of government-paid managed care business,
employers will welcome a way out of paying for commercial health insurance,
voting Boomers’ may be grateful for being fast-tracked to Medicare eligibility
and the House Democrats’ momentum will become ten times more complicated. To
the chagrin of his detractors everywhere, Mr. Trump will give the impression he
really has a chance at a second term. MFA might even pass. <o:p></o:p></span>Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-81254715178456459102017-12-11T08:17:00.000-05:002017-12-11T08:17:10.364-05:00Science or Marketing?<div abp="52">
<em abp="53">The Disease Management Care Blog's colleague, Otto Wolke, R.Ph., a former Vice President of a managed care pharmacy plan and industry leader, submitted the following post. </em></div>
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<em abp="53">He speaks truth to power.</em></div>
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With sixty plus years of observing the pharmaceutical industry, I have an urgent need to provide a perspective that I hope pharmacists, physicians, insurance benefit managers and the Federal Government will heed. As we enter a new world of personalized medicine, new FDA decisions on priority reviews and the push for faster drug review process, the line that separates science and marketing has never been more important. </div>
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While the pharmaceutical industry has produced some amazing drugs and there are many thousands of dedicated scientists, there is an unconscionable waste of healthcare dollars, not only in the US, but around the world. Only two countries allow advertising of prescription medicines: the United States and New Zealand. </div>
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That translates to $6 billion dollars that provides much more marketing than science. Those billions could be six new breakthrough drugs, or perhaps research that could discover why prescription medications are not only are <a abp="62" href="https://ethics.harvard.edu/blog/new-prescription-drugs-major-health-risk-few-offsetting-advantages" target="_blank">a major reason for hospitalizations, but also deaths</a>.</div>
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You can add the billions paid in drug liability settlements, and more billions paid in fines to the FDA for non-compliance because of faulty and/or misleading information as well as the marketing off label use. </div>
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Imagine even a portion of these additional dollars being invested in real science to produce the medicines of the future.<br abp="168" /> <br abp="169" />The recent disclosures about unethical pricing and possible collusion in the generic industry just scratches the surface of the consequence of allowing marketing instead of science to direct the industry. </div>
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This not only applies to pharma, but to the medical device industry as well.</div>
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I could write a book, but several have already been done, perhaps one of the best written by <a abp="171" href="https://en.wikipedia.org/wiki/Peter_C._G%C3%B8tzsche" target="_blank">Peter C. Gotzche, co-founder of the Cochrane Collaboration</a>. His book is entitled <a abp="227" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046551/" target="_blank"><em>Deadly Medicines and Organized Crime</em> and is aptly subtitled <em>How Big Pharma Has Corrupted Healthcare</em></a>.</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-48266063898030849232016-12-19T09:09:00.000-05:002016-12-19T09:09:02.908-05:00Clever Rap Anthem About Electronic Health Records<a href="http://zdoggmd.com/" target="_blank">ZDoggMD</a> makes some good points, slips in a sly reference about one EHR provider and salutes another.<br />
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Ten years that have passed since I wrote <a href="http://content.healthaffairs.org/content/25/4/1079.full" target="_blank">this article</a>, and we still have a way to go.<br />
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<iframe allowfullscreen="" frameborder="0" height="225" src="https://www.youtube.com/embed/xB_tSFJsjsw" width="400"></iframe>Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-24957440658334831372016-11-21T10:23:00.000-05:002016-11-29T08:16:08.662-05:00Countering the Cruel Tutelage of Healthcare Access, Quality and Cost: How mHealth Can Do It Faster, Better and Cheaper<div abp="2992">
<a abp="2993" href="https://upload.wikimedia.org/wikipedia/commons/6/6e/HD.17.005_(11949812454).jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img abp="2994" border="0" height="191" src="https://upload.wikimedia.org/wikipedia/commons/6/6e/HD.17.005_(11949812454).jpg" width="200" /></a>While there many maxims about the delivery of healthcare, the <a abp="2995" href="http://www.medsolis.com/" target="_blank">MedSolis</a> Chief Medical Officer PHB has discovered that three in particular stand out:</div>
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1) Many healthcare outcomes <a abp="2998" href="http://content.healthaffairs.org/content/32/3/459.full" target="_blank">are more a function of <i abp="2999">social, economic and cultural determinants</i></a> than <i abp="3000">medical quality. </i>Zip code trumps diagnosis code.</div>
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2) <a abp="3003" href="https://en.wikipedia.org/wiki/Supply_creates_its_own_demand" target="_blank">Say's Law</a> warns us that healthcare utilization may be a function of sevice availability rather than need. As a result, compelling innovations <a abp="3004" href="http://content.onlinejacc.org/article.aspx?articleid=1695808" target="_blank">like this</a> or <a abp="3005" href="http://gut.bmj.com/content/38/2/282.abstract" target="_blank">this</a> can be "additive" to healthcare, not "substitutive." Demand trumps discovery.</div>
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3) Healthcare access, quality and cost are interdependent, and <a abp="3008" href="http://www.ccjm.org/articles/viewpoints-opinion/article/the-health-care-iron-triangle-and-the-patient-protection-and-affordable-care-act/1ae23bd6dd20f69d980cbb43db99d9b3.html" target="_blank">improvements in one has downsides in the other two</a>. For example, price controls can lead to lower access in the form of queues. Increasing quality can drive up prices. And, Obama's healthcare reform emphasizing better <i abp="3009">access</i> arguably led to <i abp="3010">higher prices</i>. </div>
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Trump's rhetoric trumps brainy Obamacare.</div>
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Naturally, there are exceptions to every rule. And the PHB wonders if healthcare technology's mHealth may offer an important exception to rule number three.</div>
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If so, there are important implications for U.S. healthcare delivery.</div>
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An important mHealth mantra for <a abp="3017" href="http://www.medsolis.com/" target="_blank">MedSolis</a> is "<i abp="3018">faster, better, cheaper.</i>" <a abp="3019" href="http://www.who.int/goe/publications/goe_mhealth_web.pdf" target="_blank">mHealth is defined as as any medical practice supported by devices such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless technology</a>. A <a abp="3020" href="https://www.jmir.org/2015/2/e52/" target="_blank">considerable body of literature</a> on the topic shows that patients using mHealth can access the information they need to make informed choices, that those informed choices serve <a abp="3021" href="http://content.healthaffairs.org/content/32/2/216.short" target="_blank">greater engagement</a>, and that this leads to fewer avoidable complications.</div>
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Examples from the <a abp="3024" href="http://www.medsolis.com/" target="_blank">MedSolis</a> #mHealth archives:</div>
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Mary Jones* has diabetes, and uses her <a abp="3027" href="http://online.liebertpub.com/doi/abs/10.1089/tmj.2011.0119" target="_blank">smart phone paired bluetooth-enabled blood sugar monitor</a> to assess her diabetes control versus diet, exercise levels and medications. Her A1c improves, <a abp="3028" href="http://care.diabetesjournals.org/content/28/1/59.short" target="_blank">which correlates with her future health care costs</a>. She not only sees her outpatient physicians <a abp="3029" href="https://jamanetwork.com/journals/jama/fullarticle/193448" target="_blank">less often</a>, but the A1c data <a abp="3030" href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Qualified-Clinical-Data-Registry-Reporting.html" target="_blank">inform public measures of quality</a> and <a abp="3031" href="http://care.diabetesjournals.org/content/32/12/2156.short" target="_blank">decreases the likelihood of depression</a>. Ms. Jones has hit the trifecta: lower cost, higher quality and better access to more care.</div>
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William Smith* has heart failure and has just been discharged from a hospital. He uses a telemonitoring-linked home scale to detect <a abp="3034" href="http://circ.ahajournals.org/content/116/14/1549.short" target="_blank">the subtle increases in weight from fluid retention that can herald an exacerbation of his condution</a>. William knows <a abp="3035" href="http://journals.lww.com/jcnjournal/Abstract/2005/01000/The_Effects_of_a_Sliding_Scale_Diuretic_Titration.12.aspx" target="_blank">how to increase the dose of some of his medicines</a> leading to return of his weight to normal. William has <a abp="3036" href="http://www.sciencedirect.com/science/article/pii/S0002914996006765" target="_blank">avoided an unnecessary night in the emergency room</a>. What's more, <a abp="3037" href="http://pdf.smanha.com/MACRAandMIPSVolume2.pdf" target="_blank">the avoided readmission is an important measure of quality</a>. Mr. Smith has also hit the trifecta of lower cost, higher quality and better access to more care.</div>
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Bottom line: <a abp="3040" href="http://content.healthaffairs.org/content/early/2016/07/12/hlthaff.2016.0459.abstract" target="_blank">as healthcare consumes a greater fraction of the U.S. gross domestic product</a>, the cruel tutelage** of healthcare acess-cost-quality can be mitigated by faster-better-cheaper. Whether it's Obamacare, Repeal, Replace or Trumpcare, the the value proposition of mHealth will endure.</div>
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<span abp="3043" style="font-size: x-small;">*Names and scenarios are realistic, but ultimately fictional</span></div>
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<span abp="3045" style="font-size: x-small;">** With apologies to <a abp="3046" href="http://killbill.wikia.com/wiki/Chapter_8:_The_Cruel_Tutelage_of_Pai_Mei" target="_blank">Pai Mei and his fans</a></span></div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-83471050119828190272016-11-10T07:37:00.000-05:002016-11-10T07:59:22.074-05:00Winners and Losers in the Trump Health Reform UniverseWhile readers digest the reality of a Trump Presidency and Republican control of both houses of Congress, the Population Health Blog (PHB) has been trying to assess the "down ballot" implications for healthcare and mHealth providers.<br />
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While the universe has been turned upside down, its initial reaction for mHealth is bullish. As for the rest....... read on.<br />
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While he was a wacky campaigner, the PHB suspects that Mr. Trump's "campaign promises" were really opening negotiating positions. While immigration, the Supreme Court and business regulatory reform will be top of mind, he'll eventually get around to making deals in the healthcare space, because that is his nature. That is the real wild card and increases uncertainty.<br />
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That being said, what can the PHB predict?<br />
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Given Mr. Trump's and the Republican majority antipathy to Obamacare, the Affordable Care Act is likely to be gutted. While U.S. Senate Democrats can create mischief with the filibuster, many are also up for election in two years. As a result, commercial insurance premium subsidies, the minimum benefit, the IRS penalty and ACOs are toast.<br />
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Because it's working pretty well, the PHB rates it as unlikely that Congress will alter the basic underpinnings of fee-for-service Medicare and the Medicare Advantage programs. Unfortunately, however, that also means that the complex reporting and payment changes of <a href="https://www.ama-assn.org/practice-management/understanding-medicare-payment-reform-macra" target="_blank">MACRA - and its premise of "value-driven" Medicare</a> - will stay on track.<br />
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<a href="https://www.washingtonpost.com/news/wonk/wp/2016/11/09/winners-and-losers-in-the-health-care-industry-under-president-trump/" target="_blank">According to <i>The Washington Post</i></a>, more of the federal support of Medicaid will transition to block grants. The PHB suspects that when the budgeting is done, the Republicans will trade greater local leeway for less money. It remains to be seen how states will respond by altering eligibility requirements.<br />
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So, over the short term who wins and who loses?<br />
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<b>Patients lose - but slightly</b>: those who are <i>outside</i> of Medicaid, many of them will buy skinnier coverage or not buy any commercial insurance. While that will mean that many will forego needed medical care, Obamacare's deductibles were already leading in that direction. Those <i>in Medicaid</i> will find their healthcare coverage dependent on their state's fiscal priorities; on the other hand, many Governors will fight to do the right thing. <i>Medicare</i> patients will do OK. The good news is still that if anyone shows up at 3 AM with motor vehicle trauma, the system will still take care of them.<br />
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<b>Hospitals/Inpatient Service Providers lose and a lot</b>: Without premium subsidies, more persons will forego commercial health insurance, and Medicaid will have less money. Since a lot of inpatient healthcare utilization is <a href="http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2938" target="_blank">preference insensitive</a>, that means more bad debt and deeper fee schedule discounts. By the way, interest rates are destined to rise, making hospital debt more expensive. They'll consolidate, and a pro-business climate in D.C. may make this easier.<br />
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<b>Physicians neutral</b>: while physician incomes will also be buffeted by more bad debt and deeper Medicaid discounts, the PHB suspects a critical mass of docs were increasingly disenchanted with Obamacare and its impacts on their professionalism. While policymakers and organized medicine groups (such as the AMA) may argue that this is a Pyrrhic Victory, all of this will be overshadowed by <a href="http://www.modernhealthcare.com/article/20160430/MAGAZINE/304309988" target="_blank">the top line impacts of MACRA</a>, which is not going away. This will quickly eat up the docs' bandwidth. They'll continue to consolidate into larger groups, but away from hospitals, which can no longer afford them.<br />
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<b>Organized Medicine loses</b>: the AMA and many of its sister organizations supported Obamacare and stayed inside the Beltway Bubble. Eight years later, those chickens are coming home to roost. They now have to choose between being part of a new solution or being a member of the loyal opposition. Both are unpalatable.<br />
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<b>Health Technology/mHealth wins</b>: patients will look for tech solutions that offer faster, cheaper or better care that include, for example cloud-based guidance for diabetes control, remote provider advice web sites and home telemonitoring. To the degree that it offers <a href="http://diseasemanagementcareblog.blogspot.com/2014/05/additive-not-substitutive-health-care.html" target="_blank">a substitutive level of care</a>, insurers will gladly pay for it, and since there are revenue opportunities for providers, they'll pay for it too. A pro-business posture in Washington DC, a focus on other healthcare issues and less regulatory overhang means that apps, devices, gadgets, big data, The Cloud and SasS will continue to expand. The future remains bright for companies like <a href="http://www.medsolis.com/" target="_blank">MedSolis.</a><br />
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Long term? This depends more on the economy. If it can return to 3% growth and if the labor participation rate increases, more persons will be able to afford housing, transportation, education and healthcare.Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com1tag:blogger.com,1999:blog-9181810725696409953.post-72760496689471402262016-11-03T15:57:00.000-04:002016-11-03T15:57:23.241-04:00The Latest Health Wonk Review Is Up!Do you care about baseball? Do you fret about politics?<br />
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Neither does the Population Health Blog. But that doesn't mean heading over to <a href="https://wrightonhealth.wordpress.com/2016/11/03/health-wonk-review-the-game-7-of-politics-edition/" target="_blank">Brad Wright's Health Wonk Review: The Game 7 of Politics Edition at <i>Wright on Health</i></a> isn't work your time. His post skillfully ties two of America’s favorite and most contentious pastimes together.Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-82594483726560747522016-11-01T11:37:00.001-04:002016-11-01T11:37:50.014-04:00Information Technology Expertise vs. Literacy: A Lesson from the Hillary Campaign for President<a href="https://upload.wikimedia.org/wikipedia/commons/d/d2/Warning123.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="133" src="https://upload.wikimedia.org/wikipedia/commons/d/d2/Warning123.jpg" width="200" /></a><br />
Whatever Population Health Blog (PHB) readers may believe about the 1) the timing of FBI Director Comey's announcement about the discovery of a cache of Huma Abedin emails "that appear to be pertinent to the investigation," or 2) the Wikileaks hack of the Clinton emails, the campaign's pattern of lightly securing confidential information and moving it across multiple technology platforms is disconcerting.<br />
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Ms. Abedin is <a href="https://www.washingtonpost.com/world/national-security/clinton-aide-huma-abedin-has-told-people-she-doesnt-know-how-her-emails-wound-up-on-her-husbands-computer/2016/10/29/1d30c2b8-9e15-11e6-a0ed-ab0774c1eaa5_story.html" target="_blank">apparently at a loss</a> to explain how so many the "pertinent" emails ended up on a home laptop. The Population Health Blog (PHB) suspects it was a combination of <a href="http://www.vboffice.net/en/developers/save-emails-to-file-system" target="_blank">autosaving</a> and <a href="https://support.google.com/mail/answer/10957?hl=en" target="_blank">autoforwarding</a> run amok.<br />
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In the meantime, it has been reported that the Clinton campaign chair used "<a href="https://wikileaks.org/podesta-emails/emailid/22335" target="_blank">p@ssw0rd</a>" as the password for his johnATpodesta email account. Once it was targeted, the PHB believes may have been just a matter of probing it repeatedly with a series of <a href="http://www.techradar.com/news/internet/avoid-these-10-common-passwords-if-you-don-t-want-to-be-hacked-1316113" target="_blank">commonly used passwords</a>. Once one account is hacked, it can be used to email viruses and malware to unsuspecting recipients.<br />
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No one should expect that the leaders who run national political campaigns should be IT <i>experts</i>. It's also true that no one or organization is immune from an <a href="https://en.wikipedia.org/wiki/Advanced_persistent_threat" target="_blank"><i>advanced persistent threat</i></a>. But that doesn't mean that these leaders - who aspire to oversee executive branch policymaking - don't have a duty to be IT <i>literate. </i><br />
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</i> The absence of Republican leaks is intriguing. While hackers may be showing favoritism, the PHB wonders if <a href="http://archive.boston.com/news/politics/2008/articles/2008/09/18/hackers_leak_e_mails_from_palin_account/" target="_blank">this episode in 2008</a> prompted future GOP campaigns to take the threat seriously. In addition to applying IT policy and procedure (<a href="https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/Information-technology-policy.pdf" target="_blank">for example</a>) as well as relying on experts to identify and defend<a href="https://www.wired.com/insights/2014/05/protecting-crown-jewels-digital-age/" target="_blank"> the crown jewels</a>, their leaders - aware that their digital musings could end up on the front page of <i>The New York Times</i> - probably internalized some basics:<br />
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<li>While email is <a href="https://www.fluiditservices.com/blog/email-security-risks-every-business-aware-one-solution-made-clients-scream/" target="_blank">never secure</a>, the likelihood of a hack can be reduced by using unique passwords and regularly changing them;</li>
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<li>Email attachments, including <a href="http://www.pcworld.com/article/2105408/3/watch-out-for-photos-containing-malware.html" target="_blank">embedded pictures</a>, are a common method of delivering viruses and malware;</li>
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<li>There are important differences between <a href="https://www.fundera.com/blog/2016/09/09/storage-backup-data-risk" target="_blank">storage and backups</a>. The latter can resurrect an entire data base, is less prone to mismanagement and typically offers encryption.</li>
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This is not rocket science. Understanding these and other basics - i.e. having literacy - is an important piece of IT security in any organization. That's especially true in the healthcare sector, where we learned our lesson years ago. The hard way.<br />
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In numerous posts (<a href="http://diseasemanagementcareblog.blogspot.com/2012/08/more-on-corporatization-of-health-care.html" target="_blank">for example</a>), the PHB has repeatedly questioned the ability of a federal bureaucracy to competently coordinate healthcare delivery. In addition to the complexity, cronyism, concentration of risk, unintended consequences and politics, the PHB believed the health-policy illiteracy of the decision-makers made them unequal to <a href="http://diseasemanagementcareblog.blogspot.com/2009/07/president-obama-and-red-pill-blue-pill.html" target="_blank">the blue-pill vs. red-pill task</a>.<br />
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Alas, is the same true when it comes to the oversight of the United States' information infrastructure? If a future <a href="https://ballotpedia.org/Hillary_Clinton_presidential_campaign_key_staff_and_advisors,_2016" target="_blank">President, her Chief of Staff and her most trusted advisers</a> are flummoxed by or ignore the fundamentals of account passwords and backups, could this illiteracy lead to IT poor decision-making in a future White House administration?<br />
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You be the judge!<br />
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<a href="https://commons.wikimedia.org/wiki/File:Warning123.jpg" target="_blank">Image from Wikipedia</a>Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-52378593902562058862016-10-07T09:38:00.002-04:002016-10-07T09:38:22.006-04:00The Latest Health Wonk Review is Up<div abp="3613">
That's right, Paduda's Pre-election pundit ponderings is now present for your perusal and learning pleasure.</div>
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<a abp="57" href="http://www.joepaduda.com/2016/10/pre-election-pundit-ponderings/" target="_blank">Enjoy!</a></div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-91327180290345308012016-09-30T11:29:00.000-04:002016-10-07T09:27:41.771-04:00Aepple?<div abp="2994">
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<a abp="2995" href="https://upload.wikimedia.org/wikipedia/commons/1/16/SpilbergenVimala.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img abp="2996" border="0" height="134" src="https://upload.wikimedia.org/wikipedia/commons/1/16/SpilbergenVimala.jpg" width="200" /></a>According to <a abp="2997" href="http://www.bloomberg.com/news/articles/2016-09-27/aetna-to-make-apple-watch-available-in-health-monitoring-push" target="_blank">this <i abp="2998">BloombergTechnology</i> report</a>, "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 " <a abp="2999" href="https://article.wn.com/view/2016/09/28/Aetna_giving_out_Apple_Watches_to_help_track_health_aid_insu/" target="_blank">beta test a new wellness reimbursement program</a>."</div>
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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:</div>
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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 <a abp="3004" href="http://www.sciencedirect.com/science/article/pii/S0033062015000262" target="_blank">like this that shows "fitness" is not a healthcare money-saving slam dunk</a>. </div>
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2. In addition, wellness programs are far more likely to be successful if they <a abp="3007" href="http://ahp.sagepub.com/content/early/2016/09/02/0890117116664709.abstract" target="_blank">are tailored, multi-modal and sustained over time</a>. 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.</div>
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3. It is <a abp="3010" href="http://www.nytimes.com/2015/11/01/opinion/siliconvalleys-new-philanthropy.html" target="_blank">the conceit of today's Silicon Valley Robber Barons</a> to think that no problem is immune to their business models. Just like Carnegie and Rockefeller, the <a abp="3011" href="https://www.gatesnotes.com/Health/Eradicating-Malaria-in-a-Generation" target="_blank">Gates</a> and <a abp="3012" href="https://capitalresearch.org/2016/02/where-are-mark-zuckerbergs-billions-going/" target="_blank">Zuckerberg</a>s 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 "<a abp="3013" href="http://www.apple.com/newsroom/2016/09/apple-introduces-apple-watch-series-2.html" target="_blank">features to help our customers live a healthy life</a>" hype.</div>
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4. But even if some of Apple's executives are immune to the hype, their marketing department undoubtedly understands that <a abp="3016" href="http://www.tandfonline.com/doi/abs/10.2753/JOA0091-3367360204" target="_blank">"cause related" appeals</a> to societal fitness builds brand. Plus, if the <a abp="3082" href="https://en.wikipedia.org/wiki/Earned_media" target="_blank">earned media</a> helps deflect attention away from <a abp="3017" href="https://www.quora.com/Is-Apple-a-good-long-term-investment" target="_blank">Apple's lackluster stock price</a> and <a abp="3018" href="http://www.denverpost.com/2016/08/16/aetna-health-insurance-exchanges-2016/" target="_blank">Aetna's other travails</a>, all the better.</div>
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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 <i abp="3021">Apple agrees to less margin in exchange for a bulk purchase</i>. 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. </div>
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Nonetheless, the PHB is intrigued by the downstream possibilities of a <a abp="3024" href="https://en.wikipedia.org/wiki/Wintel" target="_blank">Wintel-like</a> 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. </div>
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Think Aepple. You read it here first.</div>
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<em abp="3049">*After this post was published, </em><a abp="3138" href="http://mashable.com/2016/10/01/aetna-apple-watch-data/#k19ZOt7S_Eq0" target="_blank"><em abp="3051">this news report came out</em></a><em abp="3052">.</em></div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-51995164749611124752016-08-23T10:15:00.000-04:002016-08-23T10:16:21.725-04:00When Diet Meets Technology<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb3f2SBeJj_slPbFnl8rQuYFqwltn1MjW-hY-Q_IlAOKvISPm2HmtWxmHZQoIgQ1L6vFw5rEaAGgCPYgpca6j471shTP7qDCmWT3vjerR4HyGbzEn9tyyTGpalmROl4zEbNXU7fcKwCC8/s1600/ShaeiPhone6-3S2.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb3f2SBeJj_slPbFnl8rQuYFqwltn1MjW-hY-Q_IlAOKvISPm2HmtWxmHZQoIgQ1L6vFw5rEaAGgCPYgpca6j471shTP7qDCmWT3vjerR4HyGbzEn9tyyTGpalmROl4zEbNXU7fcKwCC8/s200/ShaeiPhone6-3S2.png" width="100" /></a><i>This is a post authored by the folks <a href="https://ph360.me/" target="_blank">at ph360</a>. 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.</i><br />
<br />
Discoveries in biology, genetics, <a href="https://en.wikipedia.org/wiki/Epigenetics" target="_blank">epigenetics</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/10228599" target="_blank">biotypology</a>, and medicine are revealing that the best approach to being healthy and staying that way is to <a href="https://lup.lub.lu.se/search/publication/3f6fd9fb-bbd5-4d38-916e-f23e6b75094f" target="_blank">have a diet that is right for your body</a> (1). What works for an “average” person may – or may not - be optimum for you.<br />
<br />
So how do you know what’s right for you?<br />
<br />
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.<br />
<br />
The ideal app of the future will reconcile individual human physiology, and its adaptation to changes in environment and lifestyle, <a href="https://www.crcpress.com/Nutrigenomics-and-Nutrigenetics-in-Functional-Foods-and-Personalized-Nutrition/Ferguson/p/book/9781439876800" target="_blank">to provide more complete, detailed and personalized recommendations for staying well and reaching health goals</a> (2).<br />
<br />
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.<br />
<br />
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.<br />
<br />
<b>Enter Shae</b><br />
<br />
Matt Riemann, suffered from a rare genetic condition called <a href="http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(11)70246-0/abstract" target="_blank">Familial Amyloid Polyneuropathy</a>. This causes nerve dysfunction and has a life expectancy of approximately 10 years after onset.<br />
<br />
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.<br />
<br />
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.<br />
<br />
<b>The Details</b><br />
<br />
Shae, is built on the ph360 program. <br />
<br />
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 <a href="http://ije.oxfordjournals.org/content/38/4/1060.full" target="_blank">cardiovascular conditions</a> (3), <a href="http://care.diabetesjournals.org/content/29/7/1632.long" target="_blank">digestive health</a> (4) and even <a href="https://www.springermedizin.de/adult-height-in-relation-to-the-incidence-of-cancer-at-different/9272408" target="_blank">cancer</a> (5). Waist circumference is related to <a href="http://www.ajconline.org/article/S0002-9149(14)02074-8/references" target="_blank">cardiovascular risk</a> (6) and <a href="http://circ.ahajournals.org/content/131/Suppl_1/AMP93.short?rss=1&related-urls=yes&legid=circulationaha;131/Suppl_1/AMP93" target="_blank">diabetes</a> (7). Various body ratios, such as height to weight, have been medically associated with increased risk of <a href="http://online.liebertpub.com/doi/abs/10.1089/jwh.2006.15.1028" target="_blank">osteoporosis</a> (8), <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255099/" target="_blank">certain metabolic conditions</a> (9) and <a href="https://www.ncbi.nlm.nih.gov/pubmed/16873135" target="_blank">important hormone levels</a> (10).<br />
<br />
Health surveys are also used to get a better gauge of health risks. For example, <a href="http://cebp.aacrjournals.org/content/19/1/111.full" target="_blank">skin and hair color is associated with the risk of sun damage</a> (11), <a href="http://www.cidjournal.com/article/S0738-081X(10)00061-1/abstract" target="_blank">nail structure can indicate mineral deficiencies</a> (12), and lifestyle choices can increase or decrease the likelihood of disease onset or progression (<a href="http://jap.physiology.org/content/98/1/3.long" target="_blank">13</a>, <a href="https://link.springer.com/chapter/10.1007/978-4-431-55333-5_19" target="_blank">14</a>). <a href="https://www.springer.com/us/book/9781447119715" target="_blank">Chronobiology </a>(15) and the <a href="http://www.sciencedirect.com/science/article/pii/S0027510711002223" target="_blank">natural human aging process are considered</a> (16) to provide insights on <a href="http://onlinelibrary.wiley.com/doi/10.1002/smi.2605/abstract" target="_blank">how sleep and stress affect health and well being</a> (17) or <a href="http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0065174" target="_blank">how health risks may increase or change with age</a> (18).<br />
<br />
Shae takes ph360’s insights one step further by providing 24-7 support for ph360 users as a “<a href="https://vimeo.com/178040263" target="_blank">Virtual Health Assistant</a>.” 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.<br />
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:<br />
<br />
•<span class="Apple-tab-span" style="white-space: pre;"> </span>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.<br />
•<span class="Apple-tab-span" style="white-space: pre;"> </span>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.<br />
•<span class="Apple-tab-span" style="white-space: pre;"> </span>How to integrate Geomedicine through GPS, making recommendations for foods, activities, transportation and more based on where the person is in the world.<br />
•<span class="Apple-tab-span" style="white-space: pre;"> </span>How to optimize your schedule based on body rhythm to help minimize stress and increase productivity.<br />
<br />
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.<br />
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<b>References</b>:<br />
<br />
1. Ferguson, L. R., et al. "Guide and Position of the International Society of Nutrigenetics/Nutrigenomics on Personalised Nutrition." <i>Journal of Nutrigenetics and Nutrigenomics </i>9.1 (2016): 12-27.<br />
<br />
2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ferguson, Lynnette R., ed. Nutrigenomics and nutrigenetics in functional foods and personalized nutrition. <i>CRC Press</i>, 2013.<br />
<br />
3.<span class="Apple-tab-span" style="white-space: pre;"> </span>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." <i>International Journal of Epidemiology</i> (2009): dyp150.<br />
<br />
4.<span class="Apple-tab-span" style="white-space: pre;"> </span>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. <i>Diabetes Care</i> 2006;29:1632–7.<br />
<br />
5.<span class="Apple-tab-span" style="white-space: pre;"> </span>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." <i>Current Nutrition Reports</i> 5.1 (2016): 18-28.<br />
<br />
6.<span class="Apple-tab-span" style="white-space: pre;"> </span>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)." <i>The American Journal of Cardiology</i> 115.3 (2015): 307-315.<br />
<br />
7.<span class="Apple-tab-span" style="white-space: pre;"> </span>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." <i>Circulation</i> 131.Suppl 1 (2015): AMP93-AMP93.<br />
<br />
8.<span class="Apple-tab-span" style="white-space: pre;"> </span>Asomaning, Kofi, et al. "The association between body mass index and osteoporosis in patients referred for a bone mineral density examination." <i>Journal of Women's Health</i> 15.9 (2006): 1028-1034.<br />
<br />
9.<span class="Apple-tab-span" style="white-space: pre;"> </span>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." <i>International Journal of Obesity</i> 36.1 (2012): 119-129.<br />
<br />
10.<span class="Apple-tab-span" style="white-space: pre;"> </span>Osuna C, J. A., et al. "Relationship between BMI, total testosterone, sex hormone-binding-globulin, leptin, insulin and insulin resistance in obese men." <i>Archives of Andrology</i> 52.5 (2006): 355-361.<br />
<br />
11.<span class="Apple-tab-span" style="white-space: pre;"> </span>Veierød, Marit Bragelien, et al. "Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi." <i>Cancer Epidemiology Biomarkers & Prevention</i> 19.1 (2010): 111-120.<br />
12.<span class="Apple-tab-span" style="white-space: pre;"> </span>Cashman, Michael W., and Steven Brett Sloan. "Nutrition and nail disease." <i>Clinics in Dermatology</i> 28.4 (2010): 420-425.<br />
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13.<span class="Apple-tab-span" style="white-space: pre;"> </span>Roberts, Christian K., and R. James Barnard. "Effects of exercise and diet on chronic disease." <i> Journal of Applied Physiology</i> 98.1 (2005): 3-30.<br />
<br />
14.<span class="Apple-tab-span" style="white-space: pre;"> </span>Moritani, Toshio. "The Role of Exercise and Nutrition in Lifestyle-Related Disease." Physical Activity, Exercise, Sedentary Behavior and Health. <i>Springer Japan</i>, 2015. 237-249.<br />
<br />
15.<span class="Apple-tab-span" style="white-space: pre;"> </span>Lloyd, David, and Ernest L. Rossi, eds. Ultradian rhythms in life processes: An inquiry into fundamental principles of chronobiology and psychobiology. <i>Springer Science & Business Media</i>, 2012.<br />
<br />
16.<span class="Apple-tab-span" style="white-space: pre;"> </span>Lin, Jue, Elissa Epel, and Elizabeth Blackburn. "Telomeres and lifestyle factors: roles in cellular aging." <i>Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesi</i>s 730.1 (2012): 85-89.<br />
<br />
17.<span class="Apple-tab-span" style="white-space: pre;"> </span>Mullan, Barbara A. "Sleep, stress and health: A commentary." <i>Stress and Health</i> 30.5 (2014): 433-435.<br />
<br />
18.<span class="Apple-tab-span" style="white-space: pre;"> </span>Singh, Gitanjali M., et al. "The age-specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: a pooled analysis."<i>PloS One </i>8.7 (2013): e65174.<br />
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-63900003438266319362016-08-18T07:24:00.003-04:002016-08-18T07:24:40.298-04:00The Health Wonk Review<div abp="167">
Check out <a abp="169" href="http://bit.ly/2bApsaT" target="_blank">this Health Wonk Review post by Healthcare Economist blogger Jason Shafrin</a>. There's something for everyone: health insurance, mental health, pharmaceuticals, regulations, privacy, return on investment, value-based care and more!</div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-63473751192648822922016-08-12T10:50:00.003-04:002016-08-16T16:35:40.687-04:00The Lament About the Healthcare "Return on Investment"<a href="https://upload.wikimedia.org/wikipedia/commons/9/94/Paying_attention_to_detail_(455279239).jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="133" src="https://upload.wikimedia.org/wikipedia/commons/9/94/Paying_attention_to_detail_(455279239).jpg" width="200" /></a>The Population Health Blog had time to go back and review <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1512297" target="_blank">this <i>New England Journal</i> article on "return on investment" in healthcare</a><br />
<br />
It's abbreviated "ROI."<br />
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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 <i>chronic conditions</i> (for e.g., diabetes) it's practically unheard of other care settings (for e.g., cancer care). <br />
<br />
The authors point out that may be because:<br />
<br />
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;<br />
<br />
2) Unlike conditions like diabetes, reimbursement around the "<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925202/" target="_blank">episode of care</a>" following a new diagnosis of cancer explicitly supports a known - and profitable - suite of hospital-clinic services;<br />
<br />
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.<br />
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There are two solutions. <br />
<br />
The first is at the front-end by <i>decreasing</i> (with or without <a href="https://innovation.cms.gov/initiatives/bundled-payments/" target="_blank">bundling</a>) the reimbursement. That would presumably force the providers to gain care efficiencies that exceed the accompanying lower payments.<br />
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The second is at the back-end with "<i>shared savings</i>." This financially rewards providers who can muster efficient episodes of care. In other words, the check is the "ROI."<br />
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All good points, but written from the <i>provider</i> perspective. From the perspective of <i>buyers</i> (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.<br />
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The right balance between the <i>money</i> and <i>care</i> 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. <br />
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The PHB would offer three other points on ROI:<br />
<br />
1) <i>We've seen this movie before</i>: Using financial incentives to drive fewer hospitalizations, drugs and specialists is perilously close to rewarding the withholding of needed care.<br />
<br />
2) <i>Measuring non-events is hard</i>: "ROI" in most healthcare settings is not a classic ratio of <i>income to investment</i>, but <i>savings to investment</i> to <i>savings</i>. The latter is ultimately based on a statistical measure of what <i>doesn't happen</i> 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.<br />
<br />
3) High health status ≠ low cost: Increasing quality of life is often a function of <em>increased</em> 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.<br />
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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.<br />
<a href="https://commons.wikimedia.org/wiki/File:Paying_attention_to_detail_(455279239).jpg" target="_blank"><br /></a>
<a href="https://commons.wikimedia.org/wiki/File:Paying_attention_to_detail_(455279239).jpg" target="_blank">Image from Wikipedia</a><br />
<br />Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com1tag:blogger.com,1999:blog-9181810725696409953.post-59068923188315256602016-07-12T14:59:00.000-04:002016-07-14T15:19:42.754-04:00President Obama Writes About Health Care Reform in JAMA<div abp="167"><div abp="277"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a abp="1310" href="https://upload.wikimedia.org/wikipedia/commons/7/71/City_Sigthts_NY_Night_Tour_Bus.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img abp="1311" border="0" height="200" src="https://upload.wikimedia.org/wikipedia/commons/7/71/City_Sigthts_NY_Night_Tour_Bus.jpg" width="133" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">All aboard!</td></tr>
</tbody></table><div abp="809">In a first for the <em abp="168">Journal of the American Medical Association</em> ("<em abp="169">JAMA</em>"), President Obama has authored a <a abp="171" href="http://jama.jamanetwork.com/article.aspx?articleid=2533698" target="_blank">Special Communication on "United States Health Care Reform</a>."</div></div></div><div abp="173"><div abp="814"><br />
</div></div><div abp="173"><div abp="816">As the Population Health Blog would expect of <em>any</em> modern sitting President's essay on <em>any</em> 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</div></div><div abp="173"><div abp="818"><br />
</div></div><div abp="173"><div abp="820">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.</div></div><div abp="173"><div abp="822"><br />
</div></div><div abp="173"><div abp="824">The President goes on to putter around the edges with some suggestions for "building on progress to date":</div></div><div abp="173"><ul abp="288"><li abp="289">The <a abp="291" href="https://www.healthcare.gov/get-coverage/" target="_blank">state level Health Insurance Marketplaces</a> would benefit from "further adjustments and recalibrations."</li>
<li abp="293"><a abp="359" href="http://www.nejm.org/doi/full/10.1056/NEJMp1010866#t=article" target="_blank">Medicaid expansion</a> needs to be extended to all 50 states.</li>
<li abp="294"><a abp="415" href="http://jama.jamanetwork.com/article.aspx?articleid=2524928" target="_blank">MACRA</a>, <a abp="471" href="http://jama.jamanetwork.com/article.aspx?articleid=2281686%20" target="_blank">CMMI</a>, and <a abp="527" href="https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.html" target="_blank">ACOs</a> need to continue to grow. </li>
<li abp="295">Support should be provided for <a abp="584" href="https://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative" target="_blank">Precision Medicine</a>, the <a abp="640" href="https://www.whitehouse.gov/BRAIN" target="_blank">Brain Initiative</a> and <a abp="696" href="https://www.whitehouse.gov/CancerMoonshot" target="_blank">Cancer Moonshot.</a></li>
<li abp="296"><a abp="752" href="http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=97" target="_blank">Financial assistance for Marketplace health insurance premiums</a> should be increased.</li>
<li abp="297">A Medicare-like public plan should be offered in areas of the country "where competition is limited."</li>
<li abp="298">The federal government should "increase" transparency for drug costs, expand rebates to support lower consumer prices, and negotiate drug pricing.</li>
<li abp="299">Resist calls for repealing the excise tax on high-cost employer-provided plans.</li>
</ul></div><div abp="300"><div abp="845">He closes with "lessons for policymakers":</div></div><ul abp="301"><li abp="302">While change is difficult,<em abp="848"> "hyperpartisanship"</em> makes it doubly so. The tools of hyperpartisan sabotage include "inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation." </li>
<li abp="303">Special interests "like the pharmaceutical industry" still "pose a continued obstacle to change."</li>
<li abp="304">The ACA is an example of American middle ground pragmatism between the extremes of vouchers for all and single payer. It should continue.</li>
</ul><div><b>The PHB's Take</b></div><br />
As years of over-lawyering has taught Americans (indeed, <em abp="852">JAMA</em> has put the academic credential "JD" after Barack Obama's name), real peer-reviewed policymaking benefits not only from the <em abp="853">truth</em>, but the <em abp="854">whole truth</em>. <br />
<br />
What makes this <i>JAMA</i> piece less than the whole truth is failure to mention (other than in passing) <a abp="919" href="https://www.blogger.com/blogger.g?blogID=9181810725696409953#editor/target=post;postID=5906892318831525660" target="_blank">how lingering of the Great Recession is what blunted the majority health care inflation</a>, that a shocking amount of <a abp="1031" href="http://thehill.com/policy/healthcare/274228-cbo-cost-of-obamacare-subsidies-climbs-by-25-percent" target="_blank">treasure</a> as well as <a abp="975" href="http://www.usnews.com/opinion/blogs/opinion-blog/2014/12/17/some-democrats-say-obamacare-was-not-worth-the-political-cost" target="_blank">political capital</a> 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 <em abp="855">any</em> company doing business in the U.S. being legally compelled to share proprietary cost information is highly unlikely.<br />
<br />
Oh, and by the way, short of firing up some more money-printing presses or some real reforms, <a abp="1143" href="http://www.forbes.com/sites/mikepatton/2016/04/28/u-s-government-deficit-is-rising-again/#53bba2657146" target="_blank">Uncle Sam has no money</a> to pay for any of the additional proposed suggested goodies. There is no political appetite for shoveling any more federal money toward health care. </div><div abp="856"><br />
</div><div abp="857">Last but not least, the ACA was <em abp="858">midwifed</em> by a hyperpartisan ramrod <a abp="1087" href="http://www.washingtonpost.com/wp-dyn/content/article/2010/03/21/AR2010032100943.html" target="_blank">that failed to get even one Republican vote in either chamber of Congress</a>. This Special Communication does nothing to diminish that legacy.</div><div abp="857"></div><div abp="857">Was this a squandered opportunity to set the record straight and address some meaningful reforms?<br />
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You be the judge.</div><div abp="859"><br />
</div><div abp="860">But don't take the PHB's word it. Appearing in the same issue of <em abp="1198">JAMA</em> is <a abp="862" href="http://jama.jamanetwork.com/article.aspx?articleid=2533696" target="_blank">this editorial by the Brooking Institution's Stuart Butler</a>. He points out that <i>Medicaid and not the marketplaces</i> 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. <br />
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Oh, and then there is a consensus - now that the Recession is waning and the ACA is taking hold - <a href="http://content.healthaffairs.org/content/early/2016/07/12/hlthaff.2016.0459" target="_blank">that health care inflation is poised to accelerate</a>.</div><br />
<a abp="1200" href="https://commons.wikimedia.org/wiki/File:City_Sigthts_NY_Night_Tour_Bus.jpg" target="_blank">Image from Wikipedia</a><br />
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(Updated July 14)</div><div abp="864"><br />
</div>Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-84833424860294127162016-06-21T16:11:00.000-04:002016-06-21T16:27:55.435-04:00Problem-Based Wisdom, The Age of Em, Reputation Economics and End of Life Care<div abp="167">
<a abp="416" href="https://upload.wikimedia.org/wikipedia/commons/6/69/Image_taken_from_page_54_of_'Ballads_of_the_Bench_and_Bar%3B_or%2C_Idle_Lays_of_the_Parliament_House._(Edited_by_J._B._Paul_and_J._J._Reid.)'_(11280025073).jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img abp="417" border="0" height="171" src="https://upload.wikimedia.org/wikipedia/commons/6/69/Image_taken_from_page_54_of_'Ballads_of_the_Bench_and_Bar%3B_or%2C_Idle_Lays_of_the_Parliament_House._(Edited_by_J._B._Paul_and_J._J._Reid.)'_(11280025073).jpg" width="200" /></a>The Population Health Blog has been busy with building on the value proposition of <a abp="473" href="http://www.medsolis.com/" target="_blank">IT-enabled care management</a>, helping to plan a 2017 trade show agenda, <a abp="306" href="http://www.spartan.com/en" target="_blank">training for a race</a>, learning about cyber-security, and staying out of the way of the PHB spouse as she plans two family weddings. </div>
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But that doesn't mean it hasn't been thinking 'bout a lot of stuff. Namely:</div>
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<strong>End-of-life care</strong>: A non-physician colleague asked the PHB why the U.S. can't seem to mitigate the <a abp="268" href="http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=2008&issue=09000&article=00002&type=abstract" target="_blank">skyrocketing costs of futile treatments for persons who are dying</a>. The PHB's response was that patients and their families are less interested in <em abp="271">value</em> than they are in <em abp="273"><a abp="274" href="http://journals.lww.com/ccmjournal/Abstract/2004/11000/Absolutely_no_hope__Some_ambiguity_of_futility_of.24.aspx" target="_blank">hope</a></em>, and that "futility" is often <a abp="171" href="http://circoutcomes.ahajournals.org/content/2/6/548" target="_blank">discernible in hindsight</a>, 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 <a abp="278" href="http://annals.org/article.aspx?articleid=709077" target="_blank">local economic conflicts of interest</a>. The PHB thinks this will get worse before it gets better. It wonders if part of the answer <a abp="282" href="http://archinte.jamanetwork.com/article.aspx?articleid=769657" target="_blank">may lie in <em>Shared Decision Making</em></a>, 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.</div>
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<strong abp="285">An Interesting Book</strong>: <a abp="291" href="http://www.reputation-economics.com/" target="_blank"><em>Reputation Economics</em></a> 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. </div>
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<strong abp="294">Another Interesting Book</strong>: <a abp="287" href="http://ageofem.com/" target="_blank"><em>The Age of Em</em></a> by Robin Hanson suggests that there is less to traditional machine-based artificial intelligence than meets the eye, and that it will <em abp="295">be simpler within the next century to image and build a replica (or "emulation") of a human brain</em>. 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.....</div>
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<strong abp="296">A hot-off-the-presses PHB peer-reviewed publication</strong>: This examines how healthcare institutions' boards of directors can leverage the <em abp="297">wisdom of crowds</em>, <em abp="298">problem-based learning</em> and non-linear <em abp="299">generative governance</em> 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. "<em abp="300">Problem-based wisdom</em>" occurs when boards step back and ask more questions and seek more options. <a abp="302" href="http://online.liebertpub.com/doi/full/10.1089/heat.2016.29014.jsd" target="_blank">You can read the paper here</a>.</div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com1tag:blogger.com,1999:blog-9181810725696409953.post-16635930534803224362016-06-17T13:12:00.006-04:002016-06-17T13:12:54.080-04:00The Latest Health Wonk Review is Up!<div abp="167">
Practically nothing goes unexamined in the latest <em>Health Wonk Review,</em> which is hosted by the <a abp="262" href="http://healthaffairs.org/blog/" target="_blank"><em>Health Affairs Blog</em></a>. 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.</div>
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<a abp="171" href="http://healthaffairs.org/blog/2016/06/16/a-pot-luck-health-wonk-review/" target="_blank">Enjoy....there's something for everyone!</a></div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-26239839904927343952016-06-07T09:48:00.001-04:002016-06-07T09:48:35.251-04:00The Latest Health Wonk Review Is Up<div abp="166">
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 <a abp="168" href="http://healthblawg.com/2016/06/health-wonk-review-bustin-out.html" target="_blank">here</a>. </div>
Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-21019891420340862102016-05-25T07:02:00.000-04:002016-06-13T11:03:06.961-04:00Pricing, Product and Audience: Theranos and DTC Blood Testing<div abp="166">
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In <a abp="349" href="http://diseasemanagementcareblog.blogspot.com/2015/11/five-reasons-to-be-bullish-about.html" target="_blank">this prior post</a>, the PHB was "long" on Theranos' prospects. Since that was written, Medicare has alleged that a company lab was a "<a abp="6070" href="http://khn.org/morning-breakout/cms-theranos-practices-pose-immediate-jeopardy-to-patient-health/" target="_blank">jeopardy to patient health and safety</a>," a <a abp="6233" href="http://www.jci.org/articles/view/86318/" target="_blank">peer-reviewed study showed troubling test inaccuracies</a>, the <a abp="6289" href="http://www.nytimes.com/2016/04/19/business/theranos-sec-justice-department-investigation.html" target="_blank">Securities and Exchange Commission (SEC) has opened an investigation</a>, <a abp="6345" href="https://www.theranos.com/news/posts/theranos-announces-expansion-of-board-of-directors-and-new-organizational-structure" target="_blank">higher ups have left the company</a>, years of test results have been "<a abp="6401" href="https://www.washingtonpost.com/news/to-your-health/wp/2016/05/19/consumer-nighmare-theranos-voids-or-revises-tens-of-thousands-of-blood-test-results-wsj-reports/" target="_blank">voided</a>" and <a abp="6457" href="http://www.businessinsider.com/cms-wants-to-ban-elizabeth-holmes-from-theranos-for-2-years-2016-4" target="_blank">founder Elizabeth Holmes faces the prospect of a ban from doing business with Medicare and Medicaid</a>. <span abp="2976" style="color: blue;"><span style="color: #444444;">And to add injury to insult, Walgreens </span><a abp="2978" href="http://www.nytimes.com/2016/06/13/business/walgreens-cuts-ties-to-blood-testing-company-theranos.html" target="_blank"><span style="color: #444444;">has bailed out</span></a>.</span></div>
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<a abp="6513" href="http://www.today.com/video/theranos-ceo-elizabeth-holmes-i-m-devastated-about-blood-test-issues-668286019825" target="_blank">Talk about <span style="color: blue;"><span style="color: #444444;">CEO</span> </span>humble pie</a>.</div>
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In <a abp="344" href="http://jama.jamanetwork.com/article.aspx?articleid=2524161" target="_blank">this well-written Viewpoint</a> published in <em abp="6570">JAMA</em>, 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 <em abp="171">solution</em> of self-diagnosis and early treatment only <em abp="2480">sounds</em> revolutionary. That pales in comparison to the far larger <em abp="172">problem</em> of misdiagnosis that leads to the <em abp="2482">reality</em> of overtreatment.</div>
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Good point. But, while Theranos' prospects are clouded, <strong abp="6571">the PHB is still long on the underlying three point business model.</strong> Theranos got one right, and the other two are within reach.</div>
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1) The <em abp="2498">pricing</em> is uncoupled from opaque insurer-based fee schedules and based on rational consumer-driven price points.</div>
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3) The audience of <span abp="2980" style="color: #444444;">buyers/regulators</span> need to understand the value-based outcomes </div>
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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. <a abp="340" href="http://consumersunion.org/outrageous-health-costs/blood-test/" target="_blank">Medicare's fee schedules are ultimately "cost-plus"</a> which includes the costs of a highly inefficient care system. Think about <a abp="2632" href="http://www.nytimes.com/2013/12/03/health/as-hospital-costs-soar-single-stitch-tops-500.html?pagewanted=all" target="_blank">that $500 stitch</a> and it's little wonder <span style="color: #444444;">why </span><a abp="2689" href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwi0qOaXgfXMAhXlx4MKHbBVD_8QFggjMAE&url=http%3A%2F%2Fwww.forbes.com%2Fsites%2Fdanmunro%2F2015%2F07%2F13%2Fan-inside-look-at-the-theranos-direct-to-consumer-experience%2F&usg=AFQjCNEr2hoqAiqkkd1N4LC08c44q4p-VQ&sig2=EedFNWgJwjAsQjbNEndsHg&bvm=bv.122676328,d.amc" target="_blank"><span style="color: #444444;">consumers are so willing to forego the sticker-shock and co-pay hassles</span> to beat a retail path to Theranos' door</a>.</div>
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2) Consumer insights about screening blood tests come from <a abp="282" href="http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Screening/EP713_Screening5.html" target="_blank">combining the test results with pre-test odds, sensitivity and specificity</a>. While a smart physician can certainly help patients navigate an abnormal liver function test or a high cholesterol, <em abp="2981">distance technology combined with consumer-friendly machine intelligence (</em><a abp="336" href="http://cvdrisk.nhlbi.nih.gov/" target="_blank"><em abp="2982">here's a simple example</em></a><em abp="2983">) can also</em>. It's simply a matter of industrializing and democratizing <a abp="2945" href="http://jama.jamanetwork.com/article.aspx?articleid=366383&maxtoshow=&hits=10&RESULTFORMAT=&fulltext=%20How%20to%20use%20an%20article%20about%20a%20diagnostic%20test&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT" target="_blank">what we've known for decades</a>. And once consumers can <a abp="2854" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127365/pdf/9329312.pdf" target="_blank">understand tests' imperfections</a>, things will rationally equilibrate between under and overtreatment</div>
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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. <em abp="2864">value</em>) of any new care model. That means <em abp="346">committing considerable resources to study, document, internalize and publicly report what was achieved at what price</em>. 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.</div>
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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.</div>
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<em>Since first posted on May 25, <span style="color: blue;"><span style="color: #444444;">there have been update modifications</span>.</span></em></div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com2tag:blogger.com,1999:blog-9181810725696409953.post-32743924061854411002016-05-17T21:41:00.001-04:002016-05-17T21:41:20.702-04:0019th Hedda Gabler's Lessons for 21st Century Health Information Technology<div abp="166">
It's the 17th of May, which means it's Norway's Constitution Day. Sort of like July 4th. Which reminds the Population Health Blog.....</div>
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If you are in D.C. in the coming weeks and have an interest in health information technology (HIT), you may want to check out the <a abp="170" href="https://www.studiotheatre.org/plays/play-detail/hedda-gabler" target="_blank">Studio Theatre production of Norwegian playwright Henrik Ibsen's <em abp="171">Hedda Gabler</em>.</a> </div>
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The Population Health Blog explains.</div>
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In the two and a half hour production, Hedda struggles to reconcile her human dysfunctions with the rigid etiquette of an aristocratic age. As her dilemmas unfold, her academic husband George delights in analyzing societal trends while being unable to see the disaster unfolding in his own home. George ironically delights in knowing more, but is aware of less and less. </div>
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There's far more to the play, but what can this 19th century masterpiece teach about HIT?</div>
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While Hedda has her issues, she's still being victimized by a complex set of external social determinants. The PHB suspects playwright Ibsen was intrigued by the impact of rigid social norms in late 19th century Europe. His play examines their implications for otherwise smart people who can't and/or refuse to adapt. </div>
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Is Hedda's resistance to be reviled, or admired?</div>
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Sound familiar? Instead of a mansion decorated with dying bouquets, we have hospitals filled with the fading economics of piecemeal work. Physicians are working harder than ever to help their patients, but a new technocracy is advancing a new set of expectations. And the mainstream HIT Georges are so fascinated by making meaningful use meaningful, they are likewise unable to see the forest past all the trees. </div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-86743998049522384012016-05-05T10:26:00.002-04:002016-05-05T10:26:49.162-04:00The Latest Health Wonk Review Is Up<div abp="166" style="border-image: none;">
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<tr><td style="text-align: center;"><a abp="325" href="https://upload.wikimedia.org/wikipedia/commons/0/09/David_Copperfield_(1935)_-_trailer_screenshot.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img abp="326" border="0" height="150" src="https://upload.wikimedia.org/wikipedia/commons/0/09/David_Copperfield_(1935)_-_trailer_screenshot.jpg" width="200" /></a></td></tr>
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<a abp="168" href="https://wrightonhealth.wordpress.com/2016/05/04/health-wonk-review-pivoting-towards-the-general-edition/" target="_blank">Wright on Health pivots to an excellent "general <strike abp="169">election</strike> edition" of the Health Wonk Review.</a> After reading it, you'll be better informed than either Hillary or The Donald about health policy. </div>
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Too bad you can't <em abp="224">do</em> anything about it, but enjoy, eh?</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-5574183920837617152016-05-04T09:08:00.000-04:002016-05-05T06:42:36.202-04:00Governance Advice for Hospital Boards: Population Health<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
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<tr><td class="tr-caption" style="text-align: center;">"For 60 or 90 days of post-discharge care?"</td></tr>
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Writing in the April 26 issue of <em abp="167">JAMA</em>, <a abp="169" href="http://www.laheyhealth.org/media-room/press-releases/2014/lahey-health-announces-appointment-of-michael-s-jellinek-md-as-chief-executive-officer-for-community-network" target="_blank">Michael Jillinek of Lahey Health</a> has <a abp="273" href="http://jama.jamanetwork.com/article.aspx?articleid=2513340" target="_blank">some important advice for healthcare organization boards of directors</a>. </div>
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As income shifts from fee-for-service to global payments, the insurance risk transfers that underlie much of "population health" are an important threat to these enterprises' viability. </div>
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After a compact and well-written summary of the growth of population health, he offers six suggestions for these boards:</div>
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1. Plan on having "forthright discussions" about the difficult tradeoffs between still-remunerative fee-for-service activities (such as high-dollar imaging, lucrative surgical services) and having to invest in the Triple Aim (care coordination personnel, improving quality measures for persons with chronic illness).</div>
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<em abp="328">The Population Health Blog suspects most boards will ask why they can't have <strong abp="329">both</strong> the FFS cake and the global payment icing. If that's the case, these boards need to plan on having forthright and very lengthy discussions. It's organizationally difficult to have one mission on the 4th floor of the hospital and another in the emergency room.</em></div>
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2. If the organization's employees are enrolled in a "self-insured" health plan, bring them into a population health program sooner rather than later.</div>
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<em abp="331">Not only is this an important opportunity for a board to understand the revenue versus savings versus expenses involved in driving the clinical and care experience outcomes of population health, its only right to take this for a personal test drive before subjecting your patients to it.</em></div>
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3. Look for common ground between old fee for service and new global payment arrangements. The author suggests reducing readmissions is a good start.</div>
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<em abp="388">The PHB suggests boards ask their management teams to also pursue the care coordination "</em><a abp="333" href="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf" target="_blank"><em abp="389">chronic care management</em></a><em abp="390">" payments offered by CMS.</em></div>
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4. Start demanding population health metrics from your management team, "such as details of total medical expenditures."</div>
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<em abp="504">More details on the work of measurement </em><a abp="393" href="http://www.populationhealthalliance.org/publications.html" target="_blank"><em>can be found here</em></a><em abp="505">. The PHB has </em><a abp="449" href="http://online.liebertpub.com/doi/abs/10.1089/pop.2015.0033" target="_blank"><em abp="506">also humbly suggests here</em></a><em abp="507"> that health organizations should be prepared to invest significant resources - and discipline - into the process.</em></div>
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5. Invest in primary care, care coordination teamwork and pursue "population health pilot programs."</div>
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<em abp="508">Since the PHB believes well-intentioned CMS' programs are star-crossed (see <a abp="510" href="http://diseasemanagementcareblog.blogspot.com/2016/04/medicares-comprehensive-primary-care.html" target="_blank">here</a> and <a abp="566" href="http://diseasemanagementcareblog.blogspot.com/2009/02/medicare-coordinated-care-demonstration.html" target="_blank">here</a>), it suggests working with local commercial insurers for starters. As it reviews <a abp="622" href="https://www.pcpcc.org/results-evidence" target="_blank">resources like this</a>, they seem to have a better track record. </em></div>
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6. Ask your management team to be open population health contracting.</div>
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Hear hear, says the PHB. But it also cautions that the board needs to <a abp="678" href="http://ajm.sagepub.com/content/31/3/281" target="_blank">have individuals with the kind of industry knowledge necessary</a> to provide oversight of these contracts. </div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-15693620814594466232016-04-20T08:46:00.000-04:002016-04-21T10:32:14.408-04:00Medicare's Comprehensive Primary Care Initiative - A Two Year Report<div abp="166" style="border-image: none;">
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This is important if you think CMS' approach to supporting primary care is the fix for what ails the U.S. health care system.</div>
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Population Health Blog readers <a abp="281" href="http://diseasemanagementcareblog.blogspot.com/2015/04/the-patient-centered-medical-home.html" target="_blank">may recall</a> that two years ago, <a abp="277" href="https://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/" target="_blank">CMS launched CPC</a>. This is a still ongoing four-year multi-payer study to determine whether primary care that is "turbocharged" with <em abp="518">medical home</em>-style capabilities (see <a abp="294" href="https://www.pcpcc.org/about/medical-home" target="_blank">here</a>, <a abp="290" href="http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_25.pdf" target="_blank">here</a> and <a abp="286" href="https://innovation.cms.gov/files/x/comprehensive-primary-care-initiative-solicitation.pdf" target="_blank">here - see page 8</a>) would increase quality and lower health care costs. </div>
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The term "multi-payer" is important, because CMS recognized that clinics struggled with providing medical home care to some, but not all, patients on the basis of their insurance. Better to have one standard of care to all patients.</div>
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The NEJM article is an analysis of CPC's results after two years. </div>
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To summarize how CPC was set up, 502 clinics (from 978 applicants) across 8 states participated along with a total of 39 other insurers. In addition to the usual fee schedules, the Medicare and the other insurers paid a <em abp="299">per patient severity-based "care management fee"</em> that, on average, ranged from $8 to $40 per beneficiary per month (PBPM). Practices were also promised an additional bonus if, after two years, they reduced health care costs (i.e., shared savings) and improved various quality measures and performed well in surveys about the patients' experience of care.</div>
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These CPC practices' outcomes were compared to a <a abp="301" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144483/" target="_blank">propensity matched group</a> of non-participating practices with a similar electronic health record (EHR) infrastructure that cared for a set of patients with similar levels of disease and baseline costs. 30% of these practices had applied but were not accepted in the initiative. The total number of comparison practices was 908.</div>
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Results? Not good.</div>
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Aft the end of two years, there was no statistically (p > .05) significant difference in the growth of health care costs between the CPC and control sites. This was true whether <a abp="305" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMsa1414953&iid=f01" target="_blank">just claims costs were examined</a> (a negligible difference of $11 per patient per month favoring the CPC sites), or whether claims costs <em abp="321">plus</em> the additional fees were examined (a difference of $7 favoring the comparison sites). </div>
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When patient costs were examined by the <em abp="322">burden of disease</em>, there was no indication that more costly patients achieved any savings. </div>
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CPC sites had a statistically significant reduction in outpatient <em abp="323">office visits</em>, but not in <em abp="324">hospitalizations</em>.</div>
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While the difference in claims expense failed to be statistically significant, the total additional fees collected by the participating sites amounted to a financially significant $389,000. <em abp="325">This represented a 15% increase in their income</em>. </div>
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Was quality of care improved?</div>
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Patients with diabetes and a high burden of illness were more 3% more (p<.05) likely to receive the recommended follow-up measures to manage their disease. Otherwise, "the initiative did not have significant effects on the processes used as measures of the quality of care for the full sample." </div>
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Patient experience of care?</div>
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While surveys showed small increases in patient support, "there were no significant effects on other composite measures: ability of patients to obtain timely appointments, care, and information; how well providers communicate with patients; provider’s knowledge of care patient received from other providers; and overall rating of providers by patients."</div>
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Yikes. Ouch. Egads.</div>
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The authors correctly point out that CPC is a four year program and that it still may be too early to see the impact of the medical home turbocharging. That was pointed out in the <a abp="489" href="https://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf" target="_blank">negative one year evaluation</a>. Maybe something will turn up at three or four years.</div>
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In addition, CMS has a lot of <a abp="493" href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html" target="_blank">other value-based initiatives</a> underway, which may have biased the results. There may be a "ceiling effect" among the participating sites as well as the control sites, which were already working to reduce (for example) rehospitalizations or pursue the <a abp="497" href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/VMP/Value-Modifier-VM-or-PVBM.html" target="_blank">fee schedule modifiers</a>.</div>
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It's also important to note that the impact on the other insurers' costs and patient quality was not reported. It's possible that they saw a benefit.</div>
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The PHB's take?</div>
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1. Many care management programs achieve claims reduction with savings (<a abp="502" href="http://www.ncbi.nlm.nih.gov/pubmed/17045177" target="_blank">for example</a>) within one to two years. If CPC hasn't succeeded by now, it probably won't. And if the just-announced CPC Plus is modelled after this, it's hard to see how that program will turn out any differently.</div>
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2. It is possible that, within all the statistical noise, there were some primary care sites with particularly robust approaches to care that did bend the cost curve. CMS should seek these sites out and find out more about their secret sauce. More on that in a future post.</div>
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2. If CPC's approach to care is ultimately shown to not <a abp="506" href="http://content.healthaffairs.org/content/29/6/1131.long" target="_blank">bend the curve</a>, what's the problem? </div>
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The PHB continues <a abp="510" href="http://diseasemanagementcareblog.blogspot.com/2011/01/atul-gawandes-hot-spotters-targeted.html" target="_blank">to believe</a> that one size doesn't fit all and <em abp="512">not all patients benefit from care management</em>. Many patients, even those with chronic conditions are quite stable and need minimum attention; some patients are so sick that no intervention will keep them out of emergency rooms and hospitals. As <a abp="515" href="http://diseasemanagementcareblog.blogspot.com/2012/03/seven-step-recipe-for-making-money-with.html" target="_blank">pointed out here</a>, as more and more patients are enrolled in care management, the return on investment can paradoxically go <em abp="519">down</em>. Better to focus on patients who are not only at <em abp="520">risk</em>, but have "<em abp="521">impactable</em>" condition profiles.</div>
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In addition, CPC is based on a 5 year-old model of care. Things have changed since then: modern population health brings many more resources to the table. That not only includes in-depth analytics support (for example, to define those patients who are at greatest risk) but <em>mHealth</em>. For example, there is one innovative company (the PHB's <em>Shameless Commerce Dept</em>. over on the right side of your screen) that provides recently discharged patients with an app-enabled handheld configured to provide close follow-up. And so on.</div>
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3. It may be that care management works best in a <em abp="525">managed care setting</em>. CPC is a study of classic fee-fore-service Medicare beneficiaries with access to any participating Medicare provider. In Medicare managed care, the insurers and their providers have an even larger incentive to maximize quality and lower cost. If that's the case, CMS - despite their commitment to innovation - may want to get out of the care management business, because they just don't know how to do it.</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com1tag:blogger.com,1999:blog-9181810725696409953.post-38307069646842244062016-04-20T08:00:00.000-04:002016-04-21T10:15:32.384-04:00The Latest Health Wonk Review is Up!<div abp="166">
<a abp="266" href="http://healthsystemed.com/abouttheauthor/" target="_blank">Peggy Salvatore</a> of the <a abp="262" href="http://healthsystemed.com/" target="_blank">Health System Ed blog</a> has posted a Spring Edition of the Health Wonk Review. This brainy compendium offers links to the latest health policy insights on topics that include big pharma, pay-for-performance, the ACA, physician governance on hospital boards, commercial health insurance, extending insurance to undocumented immigrants, ACOs, primary care, and occupational medicine.</div>
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Be the early bird and <a abp="170" href="http://healthsystemed.com/health-wonk-review-the-early-bird-catches-the-worm-spring-edition/" target="_blank">catch this worm here</a>.</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-23250060881379103342016-04-14T10:48:00.000-04:002016-04-14T10:48:50.130-04:00Open Access to Health Care Research: Good Intention, Bad Idea? Thoughts from an Industry Insider<div class="separator" style="border-image: none; clear: both; text-align: center;">
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Readers interested in the $25 billion economics of peer-reviewed published research may have seen <a abp="2459" href="http://www.wsj.com/articles/the-science-of-the-tax-dollar-double-dip-1459379449" target="_blank">this article posted in the March 30 issue of <em abp="56">The Wall Street Journal</em></a>. Author <a abp="58" href="http://www.bcs.rochester.edu/people/faculty/aslin_richard/" target="_blank">Richard Aslin</a> argues that the discoveries from federally supported medical research shouldn't be hidden behind the paywalls or subscription fees of scientific publishers. </div>
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As the volume and scope of funded research has grown, says Dr. Aslin, libraries, medical schools and hospitals are paying more and more for access to study results that are ultimately the property of the U.S. taxpayer. He argues for versions of an "open access" model, in which the authors - and not the taxpayer - ultimately bear the cost of getting their findings into the public domain.<br abp="2461" /> <br abp="2462" />The Population Health Blog contacted a colleague in the medical-scientific publishing industry and asked her for her reaction. Here's her reply:<br abp="2463" /> <br abp="2464" /><em abp="113">Interesting, but frustratingly one-sided. It leaves out the critical point that someone has to pay for a CRUCIAL service that the publisher is providing - peer-review, editorial expertise, and career-making reputations for authors after the published results appear in a trustworthy, sound, and respected journal. <br abp="114" /> <br abp="115" />This is also fueled by complaints from researchers who have benefited for decades from federal subsidies (most notably student loans) who have suddenly found their inner-Reagan and cry foul when the system doesn't suit their needs.<br abp="116" /> <br abp="117" />Without the publishing industry to ensure that the science those taxpayers paid for is sound, we'd probably all be drinking Gatorade to cure Alzheimer's, because the incentives would ultimately award sponsorship to the highest bidder. Research misconduct would likely be rampant. </em></div>
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<em abp="119">To me this argument sounds like being angry that you pay taxes that the government puts towards highways and then you still have to buy a car from a reputable manufacturer. <br abp="120" /> <br abp="121" />Lots of medical journals are Open Access and the publishing industry supports it. But we're also not just slapping it on the internet. Researchers are welcome to do that with their own work, free of charge. And I wish them luck with that. I'm sure they'll need it.</em></div>
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<em abp="123">Coda: </em>The PHB - who has authored approximately 50 peer-reviewed publications - tongue-in-cheek offers another potential upside to the status quo: because the ability of mainsteam news media to truthfully and objectively report research findings <a abp="253" href="http://www.healthnewsreview.org/" target="_blank">is highly questionable</a>, lack of open access offers added consumer protections from spin, bias and innumeracy. If you think it's bad now..... </div>
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But seriously, it's also not unusual for authors to share a copy of manuscript to individual colleagues who, in the interest of advancing scientific knowledge, request it.</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com0tag:blogger.com,1999:blog-9181810725696409953.post-13862293960278201722016-04-07T09:07:00.000-04:002016-04-07T12:04:51.059-04:00A Presidential Politics-Free Health Wonk Review<div abp="2447">
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Welcome to the Health Wonk Review, a compendium of the latest insights from more than two dozen health policy blogs. Each HWR issue is hosted at a different participant's blog, with topics that include health policy, delivery infrastructure, pharma, insurance and information technology. </div>
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Your HWR host, the Population Health Blog, uses a skeptical physician's perspective to write about "systems" of care. Lately, it has focused on mHealth interventions that influence clinical and economic outcomes at a "population" level, as well as the effective governance of health enterprises.</div>
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The PHB is pleased that NONE of this issue's participants chose to mention any of the appalling lead candidates for U.S. President. Readers could use a break from the campaign cacophony, so the PHB welcomes you to the <em abp="2455">Presidential Politics-Free Health Wonk Review</em>.</div>
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Charles Gaba of <a abp="2826" href="http://acasignups.net/" target="_blank">ACASignups</a> has been tracking the progress of the Affordable Care Act. This ongoing labor of love led him to comb through too-numerous-to-count public domain sources to provide <a abp="2882" href="http://acasignups.net/16/04/05/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart" target="_blank">an original-sourced summary (with links galore) of the health insurance status for the entire U.S. population <em abp="3105">in one chart</em></a>. He calls it "ambitious." The PHB calls it gloriously detailed, credible and superb. KHN, you've met your match.</div>
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</strong><a abp="5958" href="https://plus.google.com/108014368500815051859" target="_blank">Hank Stern</a> of the <a abp="5902" href="http://www.insureblog.blogspot.com/" target="_blank">InsureBlog</a> reminds us <a abp="5538" href="http://www.insureblog.blogspot.com/2016/03/when-will-they-learn.html" target="_blank">that Medicaid fails to meet the true definition of "health insurance."</a> While beneficiaries get their health bills covered, this payment system is a government program that is ultimately paid for by taxpayers. As this <strike>form of income redistribution</strike> program expands, the opportunity for the "real" commercial insurance market dims. Ʀєfùsєηíκ indeed!</div>
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Peggy Salvatore of the <a abp="2448" href="http://healthsystemed.com/" target="_blank">Health System Ed Blog</a> provides <a abp="2449" href="http://healthsystemed.com/behavior-change-driving-digital-health-is-bubbling-up-from-the-bottom/" target="_blank">a summary of the ePharma Summit 2016</a> and regales readers with descriptions of how eHealth is helping persons who have gastrointestinal disorders, cancer or complex medication regimens be placed at the center of care. "eHealth" is reaching critical mass without the help of any government mandates or meaningful use requirements. Imagine that.</div>
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<a abp="2658" href="http://healthblawg.com/david-harlow-about" target="_blank">David Harlow</a> of the <a abp="2714" href="http://healthblawg.com/" target="_blank">HealthBlawg</a> takes <a abp="2770" href="http://healthblawg.com/2016/03/apple-carekit-iodine-start-thomas-goetz.html" target="_blank">a bite of Apple's CareKit Platform by unpacking the first app entrant from Iodine dubbed "Start."</a> Start promises to help users to individually manage both the benefits and side effects of anti-depressant medications. The app relies on a validated depression survey to assess progress, promising to take the guesswork out of treatment.</div>
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<a abp="3863" href="http://blogs.hospitalmedicine.org/Blog/about-the-authors/" target="_blank">Brad Flansbaum</a> of <a abp="3919" href="http://blogs.hospitalmedicine.org/Blog/" target="_blank">The Hospital Leader</a> not only <a abp="3807" href="http://blogs.hospitalmedicine.org/Blog/heres-why-this-is-the-best-study-on-readmissions-to-date/" target="_blank">summarizes "the best (peer-reviewed) study on (hospital) readmissions to date," but interviews the lead author</a>. As many have suspected, a significant proportion of preventable readmissions are outside the control of the institution and practically all of the current public-reporting measures fail to take that into account. Two insights are that 1) readmission rates will never go to zero, nor should they and 2) innovative interventions to minimize the risk of readmission are just now being developed. The PHB predicts that soon, no at-risk patient will leave the hospital without a dedicated app and telehealth-linked handheld device. Given the dollars at stake, perhaps those patients without handhelds should be <em abp="4047">given</em> one..... </div>
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<a abp="2688" href="https://www.blogger.com/profile/00497209843184497847" target="_blank">Roy Poses</a> from <a abp="2632" href="http://hcrenewal.blogspot.com/" target="_blank">Health Care Renewal</a> pulls aside the curtain and <a abp="2491" href="http://hcrenewal.blogspot.com/2016/03/what-you-see-is-not-what-you-get-purdue.html" target="_blank">exposes the persons ultimately responsible for the OxyContin fiasco</a>. Members of Purdue Pharmaceutical's C-suite had to pay hefty fines for the company's allegedly misleading advertising, but the upstream owners seem to have escaped scrutiny with their gazillions intact. If any of this is true, we've learned nothing about combatting corporate misdeeds.</div>
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<a abp="2546" href="http://www.healthinsurancecolorado.net/about/" target="_blank">Jay and Louise Norris</a> of the <a abp="2453" href="http://www.healthinsurancecolorado.net/" target="_blank">Colorado Health Insurance Insider Blog</a> take a <a abp="2602" href="http://www.healthinsurancecolorado.net/standardized-plans-health-savings-hsa/" target="_blank">look at some of the arcana and paranoia emerging around health savings accounts (HSAs</a>). First the arcana: HHS has a BPP about the HSA designation from QHPs that have otherwise been contrived to get around other regulations, likely promulgated in other BPPs. The paranoia is from wary conservatives, who are wondering if the liberals are unable to limit themselves to just "the nine words" by using BPPs to ultimately undermine HSAs. What could possibly go wrong? </div>
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Tom Lynch of Worker's Comp Blog <a abp="2938" href="http://workerscompinsider.com/2016/04/the-sickest-of-the-sick-the-poorest-of-the-poor/" target="_blank">reviews the history of the successful Commonwealth Care Alliance</a>. This non-profit HMO currently serves over 17,000 "dual eligibles" in Massachusetts; these persons have significant disabilities and therefore qualify for both Medicare and Medicaid. Despite huge claims costs, this HMO has been ably served by leadership who understands how money and mission underlie successful health insurance.</div>
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California's Anthony Wright of the <a abp="2994" href="http://blog.health-access.org/" target="_blank">Health Access Blog</a> is not only unapologetic about his home state gradually increasing the minimum wage to $15, <a abp="3050" href="http://blog.health-access.org/increasing-the-minimum-wage-is-good-for-our-health/" target="_blank">he argues that that level of income correlates with better insurability, out-of-pocket affordability, higher health status, improved social determinants and less need for Medicaid</a>. What's there not to like, <a abp="4108" href="http://www.npr.org/2016/04/01/472716129/one-year-on-seattle-explores-impact-of-15-minimum-wage-law" target="_blank">especially since the 48 other states can see how this ultimately works out</a>.</div>
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David Williams of the <a abp="2848" href="http://healthbusinessblog.com/" target="_blank">Health Business Blog</a> has <a abp="2709" href="http://healthbusinessblog.com/2016/04/01/is-pharma-industry-too-meek-on-pricing/" target="_blank">some thoughts for the pharmaceutical industry's efforts to justify its drug pricing policies</a>. He recommends that pharma not only embrace cost-effectiveness, but lead the fight to include that methodology in all things healthcare. They also need to help the public understand that you don't get good stuff for free: someone has to pay.</div>
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Joe Paduda of the <a abp="2906" href="http://www.joepaduda.com/" target="_blank">Managed Care Matters</a> blog attended the Rx Drug Abuse Summit and <a abp="2758" href="http://www.joepaduda.com/2016/03/rx-abuse-summit-key-takeaways/" target="_blank">has posted some of the more scary data that was presented there</a>. The vast majority of heroin users started with prescription opioid drug abuse and a lot of smart concerned people are mobilizing to address the problem. Awareness is the first step in addressing this unmitigated disaster.</div>
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And saving the best for last, in the <a abp="3107" href="http://healthaffairs.org/blog" target="_blank">Health Affairs Blog</a>, <a abp="3163" href="http://healthaffairs.org/blog/2016/03/31/tamiflu-for-all-evidence-of-morbidity-in-cdcs-antiviral-guidelines/" target="_blank">Peter Doshi, Kenneth Mandle and Forence Bourgeois scrutinize the CDC's recent recommendations on the treatment of influenza with antiviral drugs</a>. After contrasting the recommendations with the FDA's and others' more detailed analyses on the subject, the authors find the CDC's promotion of a drug of questionable effectiveness to be "<em abp="2538">problematic</em>." In academic speak, them's fighting words. This ain't over, so sit back and enjoy while the flu fur flies. </div>
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Your next Health Wonk Review will be hosted by the <a abp="4381" href="http://healthsystemed.com/" target="_blank">Health System Ed blog</a> on April 21.</div>
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Jaan Sidorovhttp://www.blogger.com/profile/05072456803925863874noreply@blogger.com5