by Albert DiPiero
Watch Dave Sanders at Ted X Portland talking about the future of healthcare.
Dave Sanders, MD &
2018 Safety and Equity Report
Tantalizing results: exercise and lifespan
In a novel new study, researchers have shown that aerobic fitness is directly related to lifespan. Researchers studied a database of 122,007 middle-aged or older men and women who underwent treadmill stress tests. Then they examined death records in the decade after the tests. The results show that people with high aerobic endurance live longer and are 80 percent less likely to die prematurely than people with the lowest endurance. And the research suggests that there is no upper limit to fitness, meaning you cannot become too fit. Instead the more fit you become, the longer you live. This is still a correlation study and does not prove causation. But the novelty of this study is that it used quantitative data from exercise tests, determined aerobic fitness and then looked at longevity, rather than using surveys that depend on people’s recollection of their exercise routine. Also of note is that the data show that being out of shape, with low endurance on treadmill tests, has the same effect on premature death as does smoking. So focus on endurance and don’t stop pushing for further improvement, because every bit counts.
November 6, 2018
Healthcare remains tops in this election, according to Google
Using Google search data, researchers at the Washington post have tracked what political issues are most important with voters across the country. The most interesting part of this work is how decisively topics that were dominating headlines and discussion a few months ago have completely fallen off the radar. For example, gun control and tariffs are just not a topic of google search today in any volume, and presumably this means that these topics are no longer of interest to the vast majority of the population. However, one topic has amazing staying power: healthcare. “In almost every county in almost every month for the past year, health care topped the charts. Medicare and Medicaid were perennially popular, as was mental health.” Immigration also remains highly popular. This persistence of healthcare again re-emphasizes that healthcare is the most important social and economic challenge of our times.
Radical proposal to lower drug prices for Medicare
On the eve of the midterm elections, the Trump administration has gone to the very heart of the rising cost of drugs. In a proposal that would save the government and Medicare beneficiaries millions of dollars every year, the administration is launching a demonstration project in which it would take the price that other countries pay for drugs, create a “pricing index, and use that as a benchmark when determining how much Medicare Part B would pay for drugs. The proposal would take effect in late 2019 or early 2020. The proposal is replete with ironies. First, today Medicare cannot negotiate drug prices. Medicare typically pays 106% of the “average sales price” for drugs, and this expense has been growing rapidly. Republicans have for years blocked proposal to enable Medicare to negotiate drug prices. So with this proposal, the administration will piggyback on the negotiations of foreign countries to obtain lower prices! Second, the administration says in has the authority to launch this demonstration project under Center for Medicare and Medicaid Innovation, which was created through the Affordable Care Act, President Obama’s landmark social program that has been the target of Trump and Republic ire for years. Nonetheless, I have always believed “reference pricing” such as this methodology holds great promise to drive innovation and control costs. Let’s savor the irony and Let’s experiment and see what happens!
Data, data everywhere, but try to get your medical records!
In an age of “Big Data”, it remains a frustratingly challenging and friction-filled experience to get your hands on your own medical records. In a recent study, researchers from Yale investigated the medical records requesting process at 83 leading hospitals by posing as patients and investigating both the forms used to request records and then by calling directly to try to obtain them. Hospitals were inconsistent and often the information on the forms did not match what the caller was told over the phone. 59 percent of the hospitals charged a higher-than-government-recommended fee for making the records available. Federal law requires the medical records be made available to patients at a reasonable cost within 30 days. “The unfortunate truth is that the system doesn’t give patients reliable or consistent responses. And some people who work in medical records departments appear to be ignorant of the law and the rights that patients have,” said Dr. Harlan Krumholz, one of the researchers on the study. Zoom+Care has made records directly available to patients on the Zoom+Care app, no request required. This cuts down on friction, and places responsibility for sharing records directly in the patient’s control.
Doctors and nurses: the next generation
This New York Times article explores the process of educating and training the next generation of providers: physicians and nurses. It does spend time on the dazzling technology, from virtual reality (VR) to life-like mannequins that are becoming increasingly common in the training of medical professionals. And it’s about time: healthcare education has barely changed in 100 years, built on a curriculum of 2 years of book learning and memorization, before being thrown into the deep end for the final two years of medical school followed by residency, where practice is gained on real, live patients. The benefits of simulation, through VR or through repetitive practice on mannequins or even patient actors, is very late in coming to healthcare, and it holds immense promise. But this article is also unique in de-emphasizing the “doctor shortage” - instead asking what type of providers should be trained - including nurse practitioners (although I would also add Physician Assistants and naturopathic doctors) - and asks whether they will be ready and willing to care for people with chronic diseases including those in underserved and poor areas. Certainly, we should be exploring and taking every advantage of emerging technologies to teach, train, test, and also bridge the geographic boundaries through digital care and communication. But at its heart, healthcare is a cultural endeavor that must emphasize caring but also high performance, teamwork, and humility, topics that rarely gets explored in medical education.
October 22, 2018
Dismal failure of health insurance
The whole point of health insurance is to protect people from the cost of direct medical care when unexpected illness strikes. But a recent survey by the New York Times, the Commonwealth Fund and the Harvard T.H. Chan School of Public Health of adults who either had a serious illness or were caring for someone who did reveals that health insurance fails in this regard. Namely, “ Among people with health insurance, more than 20 percent had trouble paying for basic necessities. More than a quarter had bills in collection, and 13 percent had borrowed money as a result of their illness.” Financial insecurity is the underlying theme of this piece. More than one third of those survey had spent all or most of their savings while sick, and 4% had declared bankruptcy. One underlying cause is that illness takes people out of the workforce. And so even with insurance, they don’t have the means to cover copays and deductibles, which have been steadily rising. Another theme is that respondents had no way of knowing what was in store for them: “They don’t know what their insurance covers.” And so when illness or injury strikes, they are rather helpless. “You’re kind of at a disadvantage as a consumer going against these big complicated systems that don’t always have your best interest at heart,” says Sarah Miller, an assistant professor at the University of Michigan who studies health insurance. One question is the role of providers in discussing the cost of care. “More than two-thirds of people in the survey said their doctors had never discussed the cost of their care.” Should they? At Zoom+Care we have found it counterproductive for providers to directly discuss prices and costs: the system is too complicated with too many variables and permutations. It really is the responsibility of the delivery system - whether clinic, hospital, network - to strive for simple, clear honest prices, that enable patients to assess value and tradeoffs. It is doable. That is the real “killer app”. But the establishment systems will fight this clarity and simplicity.
The True Cost of Drugs - Show me the Price
The Trump administration is moving forward with its proposal to force drug makers to reveal the list price of their drugs in consumer facing ads. The pharmaceutical industry is vehemently opposed and will fight this to the death on the grounds that it would be unconstitutional “compelled speech,” and would scare patients away from life-saving medications. Policy experts are also skeptical that such a policy would reduce the rising costs of drugs. They point out that “list prices” are usually just a starting point for negotiations and are nowhere near what patients end up paying, and posting list prices would just add to confusion. Our experience at Zoom+Care with our decade-long experiment in posting prices reveals that this approach is fraught with challenges. But one of the unintended consequences of such a goal is that does expose - to both patients and providers - the insanity, deceptiveness, and purposeful obfuscation of prices - a system supported and fostered by the legacy systems that benefit from confusion in the name of patient health. In our view, better to publish, expose and then deal with it, rather than preserve the current system. Transparency may be the best way to force honesty.
Another correlation: eat organic, reduce cancer risk
Selecting organic foods may be another tool in reducing your risk of developing cancer. That would certainly be one reason many people choose to pay more for the organic label. Now in a new study, researchers in France followed 70,000 adults and measured the development of cancer and their self-reported consumption of organic foods. “They found that the people who ate organic food most frequently were 25% less likely to develop any kind of cancer than the people who ate organic food the least.” There are theoretical reasons for believing this finding. Namely, pesticides can be found on non-organic foods, and some pesticides are known carcinogens. So perhaps those people who each organic foods the most frequently are less exposed to low dose pesticides and hence have a reduced risk of cancer. However, this study shows a correlation between eating organic and less cancer. And correlation is not causation. There could be many other confounding factors explain the reduced cancer rates in the organic eaters. However, perhaps it does not matter to you: there may be other reasons - including environmental - for supporting organic farming. Regardless, more research is certainly needed to study this critical topic.
Why digital health startups keep failing ?
The author of this interesting piece, Paul Yock, puts forth a believe that digital health companies keep failing because they try to apply what works in consumer oriented technology to the healthcare space. Namely, the approach of “move fast and break things just doesn’t work in healthcare. His hypothesis is that pure consumer-oriented products do not work in and have not transformed healthcare because: a) the healthcare industry is much more complicated, highly regulated and has multiple stakeholders; b) the real customers and gatekeepers are the providers and insurers. He reports that the proof of this is visible in the fact that $12 billion in annual investments in this field have rarely created game-changers as are visible in the consumer market; and “61% of digital health companies that start B2C end up pivoting to B2B and selling to other stakeholders. Dr. York certainly has the credentials to be taken seriously: he is a cardiologist, professor of medicine and bioengineering, and founder of the Byers Center for Biodesign at Stanford University - healthcare business and innovation is a very humbling experience, so I would never dismiss his views outright. Maybe his views still make sense for biotech and FDA-approved medical products; however, we are now in a new era. In all other walks of life the elite and industry experts are viewed with skepticism or out-right contempt. The same is happening in healthcare. Specifically employers, regulators, politicians and the public are fed-up with all the talk from experts when the end result remains rising prices, obfuscation, and demeaning user experience when compared to all other aspects of the consumer’s life. There now exists a multi-billion dollar health and sick-care industry outside of the mainstream. Who really believes that the solutions to our most persistent healthcare problems will really come from the old establishment? If I were betting on change and future success, I would place my chips on products and services sold directly to end-consumers, the ordinary people, who will vote with their own money for where to get wellness and sickness services.
No easy solution: Medicaid managed care and fee-for-service both fail
With the dramatic expansion of Medicaid under the Affordable Care Act (ACA), states have taken to outsourcing the program to private insurers. Medicaid now covers 75 million low income Americans at a cost of $600 billion annually. Traditional Medicaid contracts with doctors who provide care and are paid fee-for-service from the state. In these new Medicaid managed care arrangements, the states force people with Medicaid into private insurers who maintain a narrower network of providers. The state then pays a fixed fee per patient per month to the insurer. The insurer gets to keep what they don’t spend. Now billions of dollars are flowing to these private insurers with little accountability or evidence of quality or savings. While fee-for-service has always received a bad rap as wasteful, managed care is turning out to be not much better: States paid $300 billion annually to Medicaid insurers, up from $60 billion a decade ago. “If anything, our results suggest that the shift to Medicaid managed care increased Medicaid spending,” said researchers at the Congressional Budget Office and the University of Pennsylvania in a 2013 study. But Medicaid is excellent business. Centene, a California based Medicaid insurer, has seen its stock sore 400 percent since the launch of the ACA and its CEO is the highest paid executive in the health insurance industry.
There may be no easy solution. But giving insurers (and providers) monopolies by forcing patients into plans with narrow networks is a recipe for disaster. Only when data on price and quality is simple and transparent, and when patients can vote with their feet will insurers and providers get honest and compete. (Also, fee-for-service is an underrated and underappreciated consumer tool for imposing accountability). Those options may not be perfect, but it is better than all the alternatives.
The Million Lives March:
Deaths from cardiovascular disease (heart attack and stroke) have been declining in America for decades - until now. The deaths have leveled out. We are no longer making progress. In fact, deaths from heart attack and stroke are increasing in younger adults, aged 35 to 64. All bad news. Most of this excess disease is due to the epidemic of obesity and diabetes. The Centers for Disease Control and Prevention is now re-engaging the public and professionals with the goal of preventing 1 million deaths from cardiovascular disease by 2022. The savings, both financially and of suffering and pain could be astronomical. The good news
as Jane Brody writes in this New York Times piece, is that we don’t need new drugs or revolutionary new treatments. “All it really requires is the will of individuals and society to follow it.” Well, that may be a naive simplification. It is clear what individuals need to do. But it is not easy. Namely: stop smoking, reduce salt intake, control blood pressure, reduce cholesterol, take your prescribed medications, and get active. Now is the time to do this, especially if you are between 35 and 64 years old.
Could a flossing a day keep the doctor away ?
One in three Americans has high blood pressure, which is a leading risk factor for stroke and heart attacks. Researchers have now found that poor dental and oral hygiene may lead to higher blood pressure. In a research article published in the journal Hypertension, Inflamed gums and diseased teeth were associated with high blood pressure. This study does not prove that dental disease causes high blood pressure nor does it mean that treating periodontal disease would lead to improved blood pressure control. But it does suggest that dental disease may identify individuals who need more attention and treatment. And it wouldn’t hurt just to brush and floss daily, just to make sure you are doing everything possible to stay heart healthy.
October 15, 2018
Telemedicine: a demonstration of epic dysfunction
The current attempts at telemedicine reveal the dysfunctional relationship between American healthcare and modern, consumer-facing technology and seem to expose the true nature of all parties. As explained in several articles here, Medicare has now proposed paying doctors $14 for a five-minute “check-in” telemedicine “calls” with their patients. The service is to help patients determine if they need to come in for a visit. The dysfunction and intellectual conflicts abound:
Medicare called the new service a “check in” because federal law prohibits Medicare paying for telemedicine services that replace in-person office visits (but that’s its main opportunity!)
Some individual physicians are against payment for the new service because they say they already provide the service for free, and the service will reduce interactions because patients will be forced to pay a copay for the service.
But the physician head of the American Academy of Family Physicians applauded the new service:“Anytime you can tie payment to what many of us are already doing is good,” he said.
The Medicare Payment Advisory Commission, which advises to Congress, was very critical of the plan, sounding like complete luddites coming out against convenience, stating that direct-to-consumer services will increase spending: “Due to their greater convenience, these services are at risk of misuse by patients or provider.”
Medicare states the services will reduce expenses by reducing unnecessary care; but their own proposal says expenditures will increase expenditures in the long run.
Medicare while opening up payment for telecare, puts strange restrictions on the service: “Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor.”
To me, these conflicting views represent a fundamental misunderstanding of the power of new technologies and expose how healthcare fails to take advantage of breakthrough opportunities. New technologies that make life for consumers more convenient should be unleashed on the market in an open way that allows legacy systems and new entrants to uptake and deal with advances in a transparent, competitive way. There is no guarantee that such technologies will lower costs or improve quality. But I would bet that digital virtual care will in the long run would achieve just that. Experience in other markets suggest there is a high likelihood that would happen. And our Zoom+Care experience in digital care supports this view. Certainly trying to prevent the spread of such technologies or implementing laws that lock in the old way are doomed to unleash unintended consequences.
Primary care doctors not important to Millennials
We forget that the PCP - the primary care provider - has both deep roots but also shallow self-serving origins in the United States. Research consistently demonstrates that having a doctor in your neighborhood delivering frontline care improves overall health and reduces the inequities in the population's health through widespread, faster access to more appropriate services. But the notion that every American should have an personal doctor originated from an effort in the 1960s to launch family medicine as a speciality. And primary care further grew as a force in the 1990s from policy wonks and managed care advocates who viewed the “PCP” as a “gatekeeper” to more expensive care specialist care. But rarely does primary care start from the perspective of the end customer. This thoughtful article points out the generational shift that is occurring: millennials - the largest US generation - are not seeking deep relationships with a single physician. “Their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care...” and “45 percent of 18- to 29-year-olds had no primary-care provider, compared with 28 percent of those 30 to 49, 18 percent of those 50 to 64 and 12 percent age 65 and older.” This is a paradigm shift that will have profound implications for the American system. Most primary care is refusing to face this trend. The path to success today involves building a frontline system that engages these millennials and captures their lifetime care within a system.
Hiding in plain sight - alcohol
The World Health Organization just released a new report on the effects of alcohol. Society continues to underestimate the role of alcohol in health and social problems. This report claims that alcohol plays a role in 3 million deaths worldwide every year, 5.3% of all deaths and 7.2% of all premature deaths. The harmful use of alcohol is also present in many mental and behavioral disorders that lead to a reduction in quality of life for all. For example, half the people in prison were drinking when they commited the crime that landed them in the cell. We even now are still underappreciating and underreporting the role of alcohol even when it is starinus in the face, such as the behaviors that led to the Brett Kavanaugh events and underlie the #Metoo movement. When it comes to alcohol, we seem to be asleep at the wheel. The question is, what to do about it and what is the role of the state vs. individual responsibility?
Vaccine Skepticism grows
There is concern among public health officials and clinicians that a growing number of children are not getting properly vaccinated. The percentage of children under 2 years old who haven’t received any vaccinations has quadrupled since 2001. Even though the vast majority of parents follow the recommended vaccine schedules for their children, growing “vaccine skepticism” is creating pockets of undervaccinated children where preventable infectious diseases such as measles and whooping cough could spread. A report on vaccine coverage of children entering kindergarten revealed that 2.2% had an exception that let them opt out of vaccines, many for non-medical reasons. Although the percentage is low, the report noted that “this was the third consecutive school year that a slight increase was observed.” These events reflect a dangerous and growing skepticism toward elites and experts that could have profound consequences for us all. What role should the state play in forcing compliance?
October 8, 2018
Stunning rise in deductibles eat up workers’ income
Health insurance deductibles have gone up 200% in the last decade, rising eight times faster than wages. Any way you look at it, the personal cost of healthcare - whether paying for insurance or paying directly for care - seems untenable. The cost of a family health insurance policy is now almost $20,000 per year, according to a Kaiser's Employer Health Benefits Survey. Although employers pick up most of this ($14,100), workers pay $5,550, up 65% from a decade ago. High deductibles are used by employers to limit increases in premiums. But high deductibles are among the greatest drivers of consumer dissatisfaction with healthcare. Employers are also turning to direct contracting with hospitals, narrowing provider networks, and reimbursing for telemedicine as methods or reducing the rise in healthcare spending. But all of these tactics reflect the utter failure of the healthcare industry - providers, insurers, suppliers, government - to establish a framework where innovation, creativity, and competition can work to disrupt the establishment and offer better products and experiences at a lower price. That is why Amazon, Berkshire Hathaway and JPMorgan felt obligated to join forces in an attempt to improve care and reduce prices for their employees.
I want my antibiotics: we have only ourselves to blame
A new study reveals that when Americans are sick with a respiratory infection, they rate their satisfaction highest when they receive antibiotics from a medical encounter. And they readily penalize the doctor with lower ratings if they do not receive antibiotics. In this study, “...no other factor was as strongly associated with patient satisfaction as whether they received a prescription for an antibiotic.” This leads to perverse incentives for doctors to prescribe, even when no medical indication for antibiotics exists, leading to increased drug resistance which is bad for all of us. The authors suggest “it might be helpful to exclude reviews from respiratory tract infections appointments from providers' overall ratings.” Alternatively, healthcare organizations could transparently rate providers based on metrics of clinical care (which would include appropriate antibiotic prescribing) and share these data with the public. Zoom+Care has rated our quality and shared this data publicly.
Why don’t we do what is right
A new class of medications, called PCSK9 inhibitors, are a powerful reducer of cholesterol. These medications are ideal for people with certain hereditary high cholesterol that places them at great risk for deadly heart attacks. Yet, health insurers have raised numerous bureaucratic barriers, preventing patients from getting these potentially life-saving medicine. And the reason is very clear: money. The PCSK9 inhibitors have a list price of $14,600 per year and likely 10 million Americans would be medically eligible for these medications. So insurers have put in place every trick (prior authorizations, hoops of multiple tests and extensive documentation in order to delay and deny reimbursing for thee medications). Finally, now some insurers and manufacturers are coming together to make PCSK9 inhibitors available to some qualified patients.
Overtreatment: the dangers of too much care
“21 percent of medical care delivered today is unnecessary,” and costs us at least $210 billion per year. It can also hurt and kill us. This panel discussion reviews the evidence and possible solutions. Transparency is a much underutilized technique for exposing unnecessary or even just uncertain benefits of established care.
The internal conflict
Health Affairs writer John O’Shea explains the conflicting signals being sent by the current administration regarding payment reform in Medicare and the attempted move away from fee-for-service and toward patient-centered care and value-based care. He correctly notes the how excessive regulatory burdens stifle innovation and creativity. However, his review of the government-led alternative payment projects unintentionally reveals the complete insanity of the system. He discusses and compares and critiques programs MIPS, QPP, and APMs ! No one can seriously believe that meaningful solutions will from the likes of MedPAC, MACRA, PTCA ! The entire article is about how physicians will get paid. Amazingly, barely mentioned at all as a part of the solution are the customers, i.e., the patients. This is not how Amazon or Google or Apple would go about solving the healthcare system. What doctors and healthcare policy wonks fail to realize is that the public, employers and even legislators have had it with the healthcare establishment and don’t take their input seriously anymore. That is why Amazon, Berkshire Hathaway and JPMorgan have decided to go at it and fix it themselves. They don’t want to be doing this. But they have no choice. The good news is: the problem it is solvable. The right company will focus first on the customer. And we have no doubt that there will emerge a company that creates a system to for millions and millions of customers by delivering a great experience at an affordable price. It may have to take place outside of the traditional insurance and legacy medical ecosystem. But that company is waiting to break loose today.
Caffeine and Pain: have another cup of coffee
A recent small observational study suggests that regular caffeine intake may increase one’s ability to withstand pain. The authors report that “caffeine is is the most widely consumed psychoactive substance in the world,” and in laboratory settings has been used to reduce pain. Now in this study, community living subjects self-reported their caffeine consumption, averaging 170 milligrams of caffeine a day, the equivalent of about 2 cups of coffee. After seven days consecutive days of caffeine consumption, they were then tested with heat and pressure for their pain threshold and their pain tolerance. This may have clinical implications on the treatment of chronic pain. This study did not examine whether the development of caffeine tolerance affects caffeine’s possible ability to change pain perception.
Fast path to Fat: Read: New York Times - 1 in 3 Americans eat fast food each day
October 2, 2018
Kaiser is faking it - and Amazon knows it
Kaiser has long claimed to have a superior model - the integration of care and coverage. We agree that the theory is great but the factual results in the hands of Kaiser appear to be only marginally better. For example, we compared the rates for health insurance for 2019 in Multnomah County (Portland), Oregon. Here's what we found:
Kaiser costs less. But the monthly premium for 2019 is not even 3% less compared to the local BlueCross BlueShield plan and a very small local plan.
This is not the stuff of a fundamentally superior model. This is not market disruption. This is not the Amazon way.
In February 2017, Kaiser completed its acquisition of Group Health, a Seattle-based HMO, for $1.8 billion and pledged to invest at least another billion into the market. Yep, right in Amazon's backyard.
If Amazon was so impressed by Kaiser, why would it launch a massive effort to invent a new approach for its own employees? Amazon suspects that Kaiser at its core is an old-fashioned hospital system that talks a good game. This is why it is willing to invest potentially billions to go its own way.
Kaiser v Google
In 2013 New York Times ran an seemingly glowing profile of Kaiser. But when we read it more carefully, the following tension jumped out at us:
Kaiser invested $30 billion (with a B) over 10 years on information technology; yet
“They have not translated some of their strengths into better prices,” said David Lansky, the president and chief executive of the Pacific Business Group on Health, which represents employers on the West Coast, many of whom purchase coverage from Kaiser for their workers.
Isn't something very wrong if a company invests $30 billion in information technology over a decade and doesn't fundamentally outperform its competitors?
Compare this to Google which reportedly needed $25 million to go from start-up to IPO and fundamentally changes how humans access information and along the way remade advertising. Before long it would reinvent mapping and navigation, reorganize libraries, remake email and move our documents to the cloud.
How can one team (Google) with a relatively small amount of capital do so much and another with so much (Kaiser's $30B and 10 years) do relatively so little?.
Imagine the Kaiser team and the Google team sitting around their respective conference tables.
The Kaiser team is asking small-bore, mundane questions like "how do we decrease readmission rates by 3%?", "how do we move more customer support from phone-based to email?", "how do we make our operating rooms 5% more productive?".
Then see the Google team asking cosmic questions: "what if humans issued all commands with voice or even thoughts rather than fingers", "how will humans interact with other humans after phones?", "what if all the world's information wasn't just available but instantly usable?", "what if all humans used a common language?"
We are what we ask.
Read: The History of Google
Why U.S. healthcare is like my favorite vegan restaurant
I am a wannabe vegan, which means that I'm an omnivore with guilt. So, there's a vegan place in town that I like but I tend to arrive within an hour or so of the closing time. Inevitably, they are out of the dish I want. Moreover, they are typically out of many, many dishes. Since they are located across the street from a large grocery store I've always wondered why they just don't go to the grocery store when they run out of ingredients.
After experiencing this phenomenon many times I screwed up my courage to ask my server why they run out of so many dishes when a grocer is across the street - why don't they just go pick up some more spinach?
She told me, "no one has ever asked that question before?" I responded, "by no one do you mean no customers - or no employees?" She said, "neither". Really? No employee has ever said, "We're a vegan place and we're out of greens, I'll be back in a few with more greens." Guess not.
But, then I thought more about it and I realized that this is no different than U.S. healthcare. What's remarkable about U.S. healthcare are the questions that are never asked. You would think that in an industry infamous for waste, poor service and excessive costs, there would a be question-asking feeding frenzy. Nothing is further from reality. Healthcare professionals and executives don't ask that questions that make each other squirm. Plus there's simply a long list of forbidden questions.
Let's kick off the question-asking party right here, right now:
What are all things we do that add no value? Can we strip this waste out now?
What if we really paid for wellness rather than sickness?
What if we paid primary care NPs more than surgeons?
Why do doctors get paid what they are paid? Are they worth it? If not, what would make them worth it? Why don't we tell them straight up?
Why do we pay more for the same care delivered in hospitals/ERs than when delivered in a neighborhood clinic?
What if someone was offended? What if a job was eliminated? What if a regulation that we hold dear is part of the problem?
Can't wait till my next visit to the vegan place.....
Manage Like Ulysses S. Grant - not Robert E. Lee
One of U.S. Grant's underappreciated skills that catapulted him from a nobody to supreme commander of the federal army was his penchant for specific commands documented with unmistakable written language such as "Take the hill at 39° 49' 4.80" N x -77° 13' 57.00" W and report back by 1740". Unlike Grant, the courtly Lee preferred the less direct, "Take the hill - if you can." Military historians believe that this leadership difference impacted the outcomes of key battles. Too often, our executives are reluctant to be entirely clear, let alone to issue unmistakable orders. Of course, Grant-like clarity is not always the right management method, specifically in Portland, Oregon in 2018, but it is an important tool in your toolkit. Develop it and know when to use it.
Legacy Health System fined $5 million for meal and rest break violations by BOLI
Anyone who leads or manages a business that relies on employees to deliver services including healthcare, retail, restaurants, etc is familiar with the meal and break regulations to protect employees. We noted that the Legacy Health System - a major provider or healthcare services in Portland - was recently fined $5 million by the the State of Oregon Bureau of Labor and Industry (BOLI) for violating these rules. We read over the state's complaint against Legacy but couldn't fully understand the specific situations and have no basis for evaluating the merits.
But here's what we do know. If our nation and state intend to change the trajectory of healthcare costs then it must fundamentally reorient the point of care from hospitals to mobile phones, to homes, to small neighborhood outlets, to employer onsite settings. Along with this reorientation will come the shift away from a physician-focused system to one based on non-professionals and far less trained and less expensive non-physician professionals. These essential point-of-care and workforce reforms are good for patients and are required for society, but will inevitably collide with employee protection regulations.
For example, at Zoom, for over a decade our neighborhood clinics remained open during lunch in order to cater to working people - patients - who wanted to use their lunch breaks to get essential healthcare.The State of Oregon BOLI requested that Zoom close its clinics during lunch to strengthen our protections for employee meal and break requirements. Zoom complied with this request. What was clear during this process is that BOLI was doing its job as defined by state law. Its lens is employee protection - no more, no less. Unfortunately, BOLI is not required to consider patient care or the cost of care in its decision-making.
We suggest that states that are serious about confronting the rising costs of healthcare by modernizing their delivery system and healthcare workforces will need to reconsider employee meal and break protections in a broader context of healthcare access and cost.
Elon Musk is public property. Will someone let him know?
Anyone who has founded a company that became even moderately successful will know what we're talking about. At some point in a company's development, the founder, the owner, the CEO - the responsible party and public face of that company - is no longer an entirely private citizen. That person can no longer do whatever what he or she wants to do. There are employees, customers, shareholders, partners, perhaps regulators, media, and others who interconnect you with the company. That means that your every move is rightfully subject to scrutiny. You are no longer you. You can no longer do whatever strikes your fancy. You must do what the company needs you to do. Elon Musk seems to think that he can simultaneously be the Elon he wants to be and the Elon that his company needs him to be. This is an irreconcilable that will ultimately implode.
September 28, 2018
Public health complex
Public health is an under appreciated service, with “far more value per dollar than with most other types of health care spending,” according to a detailed summary written by Aaron E. Carroll is a professor of pediatrics and Austin Frakt a health economist. The theme is well known: public health initiatives (such as anti-smoking commercials, food safety inspections, and vaccination programs) save more lives than most sickness-focused programs. “The key to better health isn’t always to build more hospitals and train more specialists,” says former surgeon general Vivek Murthy. There is no doubt this is the case. And we could do more by “... addressing things we know that kill.” This New York times article came out around the same time as a research article with unexpected and facinanting results on the same topic: the United States is pretty effective in its public health work. “The United States spends more than nearly all [developed] nations on prevention, both on a per-capita basis and as a percentage of overall health spending.” And the results have been impressive in many areas, including reduced smoking, reduced drunk driving, fluoridated water, and mandatory vaccination programs. Surprisingly, some European nations such as UK and France decided after World War II to focus sickness care instead of prevention and public health. These articles call out the power of focused, cost-effective programs that target major causes of disability and death and expose the tradeoffs with spending more on curative care that touches relatively few.
America could be better
The shortcomings of the American medical system are well known, at least by conventional wisdom: the United States spends the most on health care among all the industrialized nations, yet, our disease burden higher and our outcomes are worse. Donald Rebhun, MD, MSPH, is the national medical director of HealthCare Partners, a DaVita Medical Group, argues here that the solution to organize care in integrated coordinated care organizations, especially where the providers are at “full risk” for the outcomes. Dr. Rebhun astutely emphasizes the importance of culture in successful organizations - in the cases he admires, “a culture where patients are at the center of the clinical model.” However, the reality is more complex. Research has not shown care coordination to be a significant game changer when it comes to controlling costs, as the work of Dr. J. Michael McWilliam reveals. Care coordination is a case of advocating for spending more and doing more now in order to save more later. It almost never works. And full-risk contracts in the 1990’s promoted health system and provider behaviors that triggered a major public backlash against managed care. But maybe the key lesson is than no one size fits all. Instead we should foster full innovation in care and financial models and not assume any one method is the only best way.
Secrets and Lies
Here is another example of how barriers limit competition and limit transparency, to the benefit of legacy players in healthcare. The result is complete obfuscation, which protects dominant hospital margins and reduces care, service, and options for patients. Here the Wall Street Journal explains the common deals that hospitals drive with insurers. The most obscure and pernicious of these tactics are called anti-steering clauses, that prevent insurers for guiding their members to less expensive or higher quality hospitals. Some clauses even prevent patients from seeing hospital prices at all. In 2018, this lack of disclosure and lack of transparency is mind boggling. The solution is open transparency, and a culture of competition. The hospitals would be turned on their heads and we would all be better off, as more effective, affordable higher quality innovators enter the market.
Out of the hospital: childbirth in a new setting
Turning a hospital on its head could start with childbirth. The New York Times explores the benefits of birth centers for women with low risk pregnancies who want the comfort of a home birth in a setting with medical professionals and plans for emergency care when required. For the right person, birth centers can be a big win. Only in American, where hospitals dominate the healthcare system, is a birth center considered a special breakthrough. A birth center uses lower cost professionals - midwives rather than physicians - in a less expensive setting, and focuses on the experience by emphasizing “personal attention and familiarity, including longer prenatal visits and continuous support from a midwife through labor.” As a result, the cost of delivery in these free standing centers is about half the cost of a delivery in a hospital, and the rate of caesarean section is about 6 percent, compared to 26 percent of similar low risk pregnancies. Of course the legacy providers will sow uncertainty by bringing up safety and quality. Studies in Europe and the US conclude that birth centers are safe and equal to hospitals in results for appropriate low risk pregnancies and this article provides further guidance on selecting the right center. Focusing on the customer, developing a unique experience, providing safety and cost data - seems like a winning formula.
Make it stick: exercise and sleep
New research suggests that a burst of intense cardiovascular exercise right after learning a new motor skill can help solidify and lock in the learnings. Exercise seems to make the brain more efficient in holding the neural pathways. This consolidation of learning is possibly further promoted by sleep. These are the conclusions after a study focused on rehabilitation patients, such as stroke patients, but fascinating nonetheless. The findings may have broader implications for all learning. The striving for peak performance is fueling work like this. This work may provide a simple (but not easy) way to achieve it: exercise and get a good night sleep.
Healthy Body, Sick Heart
Jane Brody, long-time Personal Health columnist for the New York Times, writes a personal story about her brother, who recently had heart bypass surgery for a critical narrowing of a coronary artery, despite staying active and taking his medications. She gives three key pieces of advice:
Don’t assume that your coronary arteries are clear just because you are trim and athletic and you live a healthy life.
Don’t ignore potential symptoms of heart disease.
If you need open-heart surgery find the most experienced surgeon who operates at a hospital with the an excellent coronary care unit.
This is wise advice, at a certain level. But it also exposes real challenges in health and sickness care that we must confront. First, there is a key phrase that we could easily gloss over. Ms. Brody writes that her brother paid attention to his health “up to a point.” Namely, “he’s lean, physically active and takes medication” to control his cholesterol and blood pressure. That is certainly better than many people do. But it is a pretty low bar. In order to really remain disease free and fit into one’s seventies will probably take much more than that. We cannot fully escape our genetics. We can minimize the potential negative effect of some deleterious family history, but it likely requires deep dedication to very physical activity, diligent avoidance of the bad foods, and adequate sleep day after day for years. It is a simple recipe but it hard work and takes time that most of us are not yet committed to pursuing. On the sickness side, if illness does strike, Ms. Brody unintentionally exposes real gaps in our system. There is no meaningful way today to find the best doctor or the best hospital. She tells a story of still depending on reputation and referral among other doctors to find the best. Better to not get stick: start the training program to achieve peak health and performance.
Fast workouts - is there a shortcut to greater strength?
Here is another study that undercuts your excuse of not having enough time to workout. In a small but compelling study, researchers have demonstrated that as little as 13 minutes of weight lifting three times per week increases a participant’s strength to the same degree as doing 70 minutes of weight lifting three times per week. They key is lifting to failure through eight to twelve repetitions through seven common weight exercises. Participants who performed more reps did have greater bulk of muscle but not greater strength. One conclusion that we all know: “A lot of people probably do not push themselves that much” when they workout says the lead author of the study. For this approach to work, you must lift to failure, meaning “you must strain the working muscles to limp exhaustion by the end of each set…”. This work builds on other studies showing that great gains in performance can come from short high intensity workouts. But you must push yourself!
September 26, 2018
Are American radiologists an endangered species?
The advent of outsourcing and offshoring the reading of x-rays along with the emergence of artificial intelligence stimulates this Politico podcast to ask, “Are American radiologists' days numbered?” In interviews with Stefan Tigges MD professor of radiology at Emory University, and Rebecca Smith-Bindman MD, a professor at University of California-San Francisco, we get two very different perspectives. Dr. Tigges tells us the story of his usual work day and in doing so makes a inadvertent but powerful case for why radiology is ripe for disruption. He comes across as a deeply caring, honest, and dedicated physician. But he says that AI and offshoring have failed because these services can not fulfill the relationship side of the work he delivers. He explains that it’s just like Napster, which also failed (umm - what about Apple music or Spotify?) He describes days where he reads 40 CT scans and 150 plain xrays and must take breaks because of mental fatigue. Some CTs have a life-threatening finding visible on only a few of the 6,000 images he had to view. I’m no computer scientist, but this all sounds like a job for AI! In contrast, Dr. Smith-Bindman provides a more nuanced story of how AI will supplement or replace diagnostic skills of the human radiologist. So the radiologist will have to change the job she does, focusing more on developing the integrated treatment plan that emerges from the radiologic findings. Radiologists who are not open to change will be left behind, she predicts. The back-story here is that all medical specialties are ripe for some type of outsourcing or AI disruption.
Read: for a deeper perspective of humans vs. machines, Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will
Apple Watch: why a heart doctor says beware
Apple has released a new Apple Watch that charges into the health and wellness space. The new Apple Watch Series 4 is a bona fide, FDA-approved medical device capable of performing an electrocardiogram (EKG) and detecting abnormal rhythms such as atrial fibrillation. The new features and the FDA imprimatur push the Apple Watch to a new level of leadership in the health space. And how does the medical establishment react? In this article, John Mandrola MD, a cardiologist writes, “As a heart doctor, my opinion is that if you think an Apple Watch is nifty, buy one. But do not buy it for your health. It will not improve your health, and it could even bring you harm. In particular, I’m concerned about the problems that arise when we screen healthy people.... Sending hundreds of thousands of wrongly diagnosed people to the doctor scares me.” Dr. Mandrola accurately explains the pitfalls of over-detecting minor variations in a large population. But this critique falls into a common pattern of health care experts: namely, over-valuing precision and under-valuing the power of giving consumers tools that motivate self-change. The real story here is not the EKG or the diagnosis of atrial fibrillation, but the future implications of highly motivated and empowered consumers. Dr. Mandrola need not worry: as new features get released, people are not going to flock to doctors. They will share their the data with their coaches, trainers, and friends to improve their health and performance.
The Bezos high performance routine: sleep well, wake up early, and putter around
Once you dig past the feel-good, personal stories of a titan at home, we find here some possible gems to peak performance. Amazon founder and CEO Jeff Bezos calls out a few important habits that are worth a closer look. 1) He “prioritizes sleep,” focusing on getting 8 hours per night. The exact number of hours of sleep that is optimal remains a subject of active debate. But one thing that is beyond question, sleeping less that 7 hours is associated with reduced energy, poor decision making, reduced productivity and chronic health problems. 2) He reports that he is not rushed: he “putters around” in the morning, reading the paper, having coffee, doing the dishes. Quiet, mindless tasks may have the power to rejuvenate creativity. 3) He schedules his most important work for times when he knows his mind is at peak power. This is critical. Mr. Bezos, and most of us, have a fairly narrow window each day when we are most alert, engaged, productive, creative. Don’t schedule tough meetings requiring complex decisions when you are tired. The outcome will rarely be good.
The role of dairy intake on cardiovascular health
There is a longstanding impression that consuming dairy products increases one's risk of cardiovascular disease. Guidelines re-enforce these recommendations. However, in a new study from The Lancet, researchers followed 130,000 people for over nine years and analyzed their risk of having a cardiovascular event. Diet histories were collected on all subjects at the beginning of the study. Consuming more than two servings daily of dairy was associated with a lower risk a major cardiovascular event, compared with no dairy intake. The authors conclude that “Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational population” and “consumption of dairy products should not be discouraged and perhaps should even be encouraged in low-income and middle-income countries where dairy consumption is low.” This study was funded by the dairy industry and it is important to realize that this type of study cannot prove causation, but it continues a trend of studies suggesting that higher fat products are not as nefarious as previously assumed.
Read: The Lancet article
Dietary diversity may be associated with worse health and obesity
Eating a variety of foods is a recommendation that originated in the early 20th century to promote adequate nutrient intake. But there is now evidence that in today’s modern world, dietary variety is associated with a high energy, higher calorie diet of processed foods and high sugar foods. An advisory from the American Heart Association reviews the data and suggests that we may be better off focusing on a diet that emphasizes “plant foods, protein sources, low-fat dairy products, vegetable oils, and nuts and limits consumption of sweets, sugar-sweetened beverages, and red meats.” This is a commonsense approach that is now backed by increasing data.
Read: The full Advisory
Read: 2015–2020 Dietary Guidelines for Americans, from The U.S. Departments of Agriculture and Health and Human Services
Will consulting firm help Atul Gawande find his “Beginner’s Mind”?
Atul Gawande MD, the CEO of the healthcare startup formed by Amazon, Berkshire Hathaway and JPMorgan Chase has apparently engaged Monitor Group, a global consulting branch of Deloitte to help him develop the strategy to care for patients with chronic illness. Dr. Gawande, the Harvard professor and surgeon, is an insightful student of healthcare and a brilliant author. Using an established consulting group is a far cry from the launch of the company, when Jeff Bezos proclaimed: “We said at the outset that the degree of difficulty is high and success is going to require an expert's knowledge, a beginner's mind, and a long-term orientation … Atul embodies all three.” If the engagement of Monitor Group is true, I can guess what Dr. Gawande would write if he were reporting on the story: “Nothing original or game-changing will come from a consulting firm. This is a recipe for creating a generic health service. This may even signal the death knell of this company.” Well, let’s wait and see.
An aspirin a day does not always keep the doctor away
I frequently see patients who were started on a daily aspirin years ago to reduce their risk of heart attack. But is this effective or even safe? The answer for healthy, elderly patients is now clearly, No, based on a major new study. The study followed for 5 years 19,000 people age 65 and older in the United States and Australia who were randomized to aspirin or placebo. This study revealed that in healthy elderly (no know cardiovascular disease) should not take aspirin: "the risks outweigh the benefits for taking low-dose aspirin”: daily aspirin increases the risk of potentially life-threatening bleeding. Those who received aspirin were more likely to die of cancer, although the reason for this is not yet clear. This study should not change recommendations for other populations: people who have had a heart attack can significantly reduce their risk of another by taking a daily aspirin. And there is decent evidence that people younger than 70 who are at 10% risk of a heart attack could prevent such an event by taking daily aspirin. But for those healthy elderly, it is time to stop the aspirin.
Read: an NPR article summary of the findings from the most recent research
Read: the original New England Journal of Medicine research
Read: recommendations Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer
Closing the loopholes that permit devastating surprise medical bills
In an outbreak of bipartisanship, senators have unveiled draft legislation meant to protect consumers from unexpected massive medical bills. Those surprise bills are usually due to patients being seen by doctors who are “out-of-network” and not contracted with the patient’s insurance. Although states have laws preventing these situations, the key story here is that state laws do not regulate health plans offered by “self-insured” employers and unions. These health plans are governed only by federal law. And today 61% of privately insured Americans get health insurance through self-funded, self-insured employers and other such organizations. Some recent egregious cases of surprise bills occurred in situations where the patient had a self-insured employer plan. Today Federal law does not prevent “balance billing” in these cases. The new legislation proposes a) preventing balance billing for care received during emergencies; b) prohibiting balance billing from out-of-network providers who are delivering care to patients how are in a hospital that is in network with the patient’s insurance; c) required written notification of patients (after they are medically stable) when they are receiving emergency care in hospital that is not in their insurance network.
How risk aversion and careerism drive science
Diabetes hiding in plain sight
Sugar all over
What is physician burnout and does it matter?
Relax and be yourself