Health Policy Dialog

What do you think about the Physician Group Practice Demo project?

2010-12-22T22:11:00.001-05:00

Been a long time since we wrote on this, but was wondering what you all are thinking about ACOs and the results of the PGP Demo project released earlier this month.

A link from this week's NEJM describing the results here.

And the original description and results from the PGP Demo project here

NEJM -- Failing to Thrive

2010-02-11T19:32:00.000-05:00

Wonderful article from a former co-resident from MGH.

NEJM -- Failing to Thrive

How much governance over GPH funds is enough?

2010-01-31T15:19:00.000-05:00

Been awhile since any of us has posted. I thought I'd start us up again. I came across this piece in Reuters -

Global healthcare fraud costs put at $260 billion | Reuters

A study by the European Healthcare Fraud and Corruption Network (EHFCN) and the Center for Counter Fraud Services (CCFS) at Britain's Portsmouth University found that 5.59 percent of annual global health spending is lost to mistakes or corruption.

A ~5% loss is not that bad, actually. And in all the global public health work that I have done, a tremendous amount of energy, human and financial resources is spent on reducing funding fraud.

I wonder if the investment in keeping this down to 5% is worth it - or if we allowed the total amount of fraud to increase, but spend less on policing, that actually more money would get to end recipients.

This isn't an easy one - and I don't know the answer - but I think it's worth asking ourselves how much governance over funding is enough governance? Are we policing the funds too much, and wasting time and money? Or are we not policing enough, and do people think that this 5% is too much of a loss?

Bittersweet Victory

2009-12-21T14:33:00.006-05:00

The senate finally has the 60 votes it needs to avoid a filibuster from the increasingly ridiculous Republicans, who, for purely political reasons, have pulled out every trick in the book to obstruct health care reform. While this is certainly a good thing, my sentiments are mixed. On the one hand, health care will be extended to 31 million new people. On the other hand, Senator Reid's bill has way too many silly sweetheart deals, crazy payment schemes, and takes away the strongest lever for bringing down health care costs, i.e. the public option.

Some highlights of the "compromises" Democrats have made to get the bill passed:

Nebraska's Ben Nelson was able to get extra Medicaid funding for his state. Reminds me of a 1st round draft pick petulantly holding out for a better contract.
The ability for states to choose if their insurance exchange will pay for abortions.
A two-tiered insurance system for people who want to have an abortion. I.e. you have to buy extra insurance in case you think you might want to have an abortion at some point. Ironically, the Catholic Church AND Pro-Choice both oppose this part of the bill.
At least two national insurance providers chosen by the Office of Personnel Management, the same folks who run Congress' health plan.
Higher penalties on "Cadillac" health plans excluding plans for people in high-risk jobs like police, firefighters, miners, and longshoremen.
Higher penalties on the rich - 0.9% of income if you make $200K as an individual or $250K as a family.
A tax on indoor tanning salons in lieu of a tax on plastic surgeons. I wonder if Beverly Hills has its own lobbyist.

All in all, I think this bill is necessary and it would be a disaster if it didn't pass in some form or another. Sadly, I think the forest is being lost for the trees - in my mind we have to pass health care reform to get three achieve three big outputs. 1) Cover as many people as possible. 2) Don't allow Insurance Companies to "cherry pick" customers. 3) Keep costs low by increasing competition and rewarding efficiency.

Health Insurers Caught Paying Facebook Gamers Virtual Currency To Oppose Reform Bill

2009-12-09T17:58:00.000-05:00

This is unbelievable. Thanks to Jeff for bringing it to my attention.

Health Insurers Caught Paying Facebook Gamers Virtual Currency To Oppose Reform Bill

Am pasting the article below, but credit goes to the authors from the link above:

Health insurance industry trade groups opposed to President Obama's health care reform bill are paying Facebook users fake money -- called "virtual currency" -- to send letters to Congress protesting the bill.

Here's how it's happening:

Facebook users play a social game, like "FarmVille" or "Friends For Sale." They get addicted to it. Eager to accelerate their progress inside the game, the gamers buy "virtual goods" such as a machine gun for "Mafia Wars." But these gamers don't buy these virtual goods with real money. They use virtual currency.

The gamers get virtual currency three ways:

Winning it playing the games
Paying for it with real money
By accepting offers from third-parties -- usually companies like online movie rentals service Netflix -- who agree to give the gamer virtual currency so long as that gamer agrees to try a product or service. This is done through an "offers" provider -- a middleman that brings the companies like Netflix, the Facebook gamemakers, and the Facebook gamemaker's users together.

It's this third method that an anti-reform group called "Get Health Reform Right" is using to pay gamers virtual currency for their support.

Instead of asking the gamers to try a product the way Netflix would, "Get Health Reform Right" requires gamers to take a survey, which, upon completion, automatically sends the following email to their Congressional Rep:

"I am concerned a new government plan could cause me to lose the employer coverage I have today. More government bureaucracy will only create more problems, not solve the ones we have."

OMGPOP CEO Dan Porter spotted the survey and took a screenshot for us. (Click on the image at the right to expand it.)

What is this practice called?

Paying people to act like political supporters is called "astroturfing," because its fake grass-roots campaigning. So maybe this should be called Virtual astroturfing. Virtual-turfing? Astroturfing 2.0?

Who are the people behind this?

Get Health Reform Right describes itself as a "project of organizations whose shared mission is to ensure consumers continue to have access to employer-sponsored healthcare plans."

We are concerned about federal legislation that would create new government bureaucracies that would unravel the workplace healthcare system where more than 160 million people get their coverage.

Under the "Who We Are" tab on GetHealthReformRight.org, the following organizations are listed:

Who are the gamers filling out the survey and sending emails to Congress?

Facebook gamers tend to fall into two groups: women in their 30s and 40s and teenagers of both sexes.

Is this legal?

Astroturfing, which involves real money, is not illegal, We can't imagine virtual curreny astroturfing would be illegal either. Whether or not it's ethical is a different question.

Who is profiting from this?

According to OMGPOP CEO Dan Porter, the middleman facilitating this transaction in multiple Facebook games is called Gambit. Up until a few weeks ago, these games included big hits like Zynga's Mafia Wars and FarmVille. Zynga has since removed all offers from its games. On its Web site, Gambit says its clients include:

#1 MySpace Developer
20%+ of top 10 Facebook applications
SmallWorlds.com
School Vandals
Foopets.com
2 Top 100 websites
...and over 150+ more

One important thing to remember:

Gambit is just the platform here, bringing three parties together: gamers seeking currency, game-makers seeking monetization, and companies (and, apparently lobbying groups) looking for customers.

OMGPOP CEO Dan Porter tells us it's most likely the case that Get Health Care Reform agreed to pay an ad agency for every letter-writer it recruited. Dan supposes it was this third-party that bundled the above survey with several others and submitted it into Gambit's offer network.

Update: We reached out to Gambit CEO Noah Kagan for clarification. He told us:

"It's not that Dan is wrong. But we don't run hot political issues. You don't have any evidence that this is from Gambit. We don't condone this in our system. Sometimes stuff does happen, but we've been very proactive in making sure that there's not negative offers in our system."

To this, Dan replied:

"My point all along had little to do with the Gambit platform. We are testing it in house and will deploy it and it has controls for how conservative a partner wants to be. I wouldn't use them if I didn't think it would provide value for our users in a safe way. Gambit and every other offers company simply bundle in offers from outside vendors. The primary distributers of this fake activism are companies you will never know, like webclients.net doing business under eltpath.com. [They] distribute this stuff to sources all over the web from from freecomputer4u to sweepstakes promotions to offer providers."

The response from Get Health Care Reform:

We've also contacted Get Health Care Reform using an email address listed on their Web site. We received the following message back:

Google tried to deliver your message, but it was rejected by the recipient domain. We recommend contacting the other email provider for further information about the cause of this error. The error that the other server returned was: 553 553 sorry, that domain isn't in my list of allowed rcpthosts (#5.7.1) (state 14).

How the Senate bill would contain the cost of health care : The New Yorker

2009-12-09T00:24:00.000-05:00

Gawande has a new article out on the health care bill

How the Senate bill would contain the cost of health care : The New Yorker

Dr. Gawande writes:

Turn to Page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is … pilot programs. … Where we crave sweeping transformation, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

Gawande draws parallels to the history of American agriculture when the country slowly updated farming practices through a series of government-guided pilot programs. He argues that the health care bill will achieve the same end result, even though there is no one big hammer to control costs, just a lot of little ones.

Pick up the Senate health-care bill — yes, all 2,074 pages — and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

There is a danger in drawing parallels to other industries - I know that as a consultant - it is one of our downfalls when we try to draw a line with only one data point - but seems like an interesting parallel. Agriculture was their health care - a major source of the economy that needed a major overhaul to keep America competitive.

Regardless, I'm continually impressed by Gawande's thinking and prose.

Getting the Facts Straight on Health Care Reform

2009-12-04T05:22:00.002-05:00

Wow, just read an awesome article by an MIT economist Jonathan Gruber in the NEJM. Finally someone has provided a cogent, well researched, and passionate rebuttal to all of the scurrilous talk that's been flying around in Congress. I was feeling a little down about health care reform watching the news, but reading this article has made me believe again! We absolutely must pass something substantial this year, and Gruber has basically bashed every possible argument against reform.

Slightly random

2009-12-02T08:24:00.000-05:00

This is not health care related. I saw this small article buried in the nytimes -

Darpa Puts On Contest to Find 10 Red Balloons Across U.S. - NYTimes.com

It reminded me of the Xprize that Kedar had posted a few months back about developing a health care system. DARPA - the military research unit - is putting up a $40k to see which group can identify the location of ten balloons on one day located throughout the country.

I don't get it. They say it's to learn about behavior of creative groups in collaborative situations. I think it takes its cue from the Netflix $1 million prize which was for a group that could improve the netflix movie suggestions software. When I read between the lines, however, it feels like you could replace the word "balloon" with "terrorist" and you get a sense of what the agency is trying to learn. But haven't we for ages posted reward signs for wanted criminals and relied on the public citizenry to assist the police and military in finding "red balloons" ? I don't get. What are they trying to get out of this experiment?

Sorry for the random non-health care post. Was just really curious to me.

Pricing in health care

2009-11-23T12:06:00.000-05:00

this is a bit of a stream of consciousness post - so apologies in advance -

I came across this article on GE's change in their health care plan:

Health Care: GE Gets Radical - BusinessWeek

They are essentially changing from a traditional high up front premium, predictable co-pay model to one where there is greater price transparency given that there is a higher deductible, lower premium.

Interestingly, my own employer recently changed health benefits from what was a "cadillac" plan (insurance plans that shield consumers from the true price of health care - the types of plans that are given to high priced executives or union employees) to something more reasonable, with slightly more price transparency - tiered co-pays that gives the consumer at least a modicum of insight that some drugs and services are more expensive than others.

As pricing becomes more transparent in health care (btw we've been talking about price for years now - health savings accounts were supposed to transform health care as we all became more price sensitive - but instead most of us use it to buy eyeglasses and get dental work) it's important to understand how pricing works in health care.

A bit more on pricing:

As you prob know from an earlier post, I'm a big fan of the baseline scenario blog - an extremely well written blog about finance. The folks at the baseline scenario also produce the Planet Money podcast for NPR.

They have recently been looking into pricing in the US health system. they had two very well produced segments on pricing for MRIs.
The first is at this link - and worth a listen - gives a fantastic historic overview of how we developed a fee-for-service system in health care, and how price has become so perverse in health care. Jeff and I had an argument about why partners health care takes such big price hikes in boston - and this podcast explains a bit why institutions like partners can justify taking those price hikes in services.

Then there's a follow up on pricing for MRIs in other countries - the podcast is at this link . what they find is that pricing for MRIs in japan are substantially lower. However, what's fascinating about the japanese health care system is that their approach to controlling health care costs is to reduce price. Since 1990, the government has implemented a strict policy that has capped increases in both medical - treatment fees and the price of drugs to around 2 percent annually since 1995 (muc lower than any other OECD country). Theoretically this makes sense, if you pay less then health care costs should go down. Right? Wrong. What happened in japan is there has been an expansion of health care providers - supply has gone up, japan's population is ageing very fast, technology is growing faster than price decreases, japan's wealth has triggered more visits to the doctor, - and physicians, the finely tuned economic beings that they are, have compensated with declining price with increasing volume. Remember basic microeconomics? Price times quantity equals revenue. If price goes down, a rational economic being increases quantity. Therefore, japan is the most medicalized society in the world - On average, the Japanese see physicians almost 14 times a year, three times the number of visits in other developed countries!

Alright - I'll stop here - take a listen to the podcasts, and I'll try to write more about consumer directed health plans in my next post.

When Less Isn't More

2009-11-20T21:40:00.002-05:00

The United States Preventative Services Task Force just recently changed the recommendations for breast and cervical cancer screening prompting an outcry from rationing sensationalists that government is again trying to kill its citizens. In summary, they basically said that for average risk women, you don't have to do mammograms until age 50, and even then, only every two years. They've also said to do away with self breast exams, which have been proven to not reduce mortality since the huge trial that came out of China in 2004. The same is likely to come out for cervical screening - biennial screening starting at 21. These recommendations are made by very smart people who have looked at the data and found that the previous screening remmendations were not only overkill, they were probably causing more harm than good. Yes, a rare occurence when evidence appears to outweigh emotion. Yet the crazies are still going to get upset that this is really a way to reduce costs - some have even called this a subversive attempt at "female population control."
I, for one, applaud the USPSTF's courage in trying to shift the way American's consume healthcare. Part of the reason why costs in this country countinue to skyrocket is our complete addiction and over consumption of medications, imaging, and procedures. The funny thing is, I think our national anxiety level is such that people don't think it's a relief to hear it's OK to test less. Let's say, for example you ask 100 women: would you rather be told you have a suspicious lesion and find out it's benign or not be told at all? I bet 75% would prefer to go through the testing, the trauma, and the worry even though in the end, the outcome is the same, and all you did was waste time, money, and peace of mind. It's the fear of the very rare occurrence and the media frenzy that surrounds the missed diagnosis of breast cancer in a 38 year old that breeds this level of anxiety - no one ever hears about the woman who gets staph mastitis from the unnecessary biopsy...

Hilarious

2009-11-18T17:10:00.000-05:00

This picture says alot -

Letters Lost, Meaning Found - City Room Blog - NYTimes.com

Is Brent James the savior of American health care?

2009-11-09T16:07:00.002-05:00

If you read this week's Sunday New York Times Magazine, you saw this article about Brent James, the chief quality officer at Intermountain Health in Utah. The premise of the article, and Dr. James' philosophy is that data, systems thinking, and process improvement are the absolute best ways to improve patient outcomes.

For a while now, I've rejected the prevailing wisdom that individualized patient care is the best care. The US prides itself on the doctor's ability to decide what the right treatment is for any given condition, allowing him/her to tailor the panoply of available therapeutic options to make it just right for the patient. Of course, these choices are influenced by reimbursements, what's easiest for the doctor, and what restaurant the pharmaceutical rep lured you to last week. Naturally, if you ask doctors why they do what they do, they claim their actions are evidenced-based, yet the data overwhelmingly suggests enormous variation in physician practice.

In contrast, Intermountain has developed hundreds of protocols for routine care, which essentially automate decision making down to the level of what dose of beta blocker to prescribe for heart failure. The outcomes under this system beat the rest of the nation, and interestingly, doctors are not upset about the computerization of medicine. In fact, many docs feel that these protocols help them a) understand the evidence base, and b) relieve them of the myriad complex decisions that have to be made for every patient and are often overlooked during the course of a busy day.

While I think that the "Intermountain Way" isn't perfect, I think it's a great example of an organization who is really thinking about how to streamline and "hardwire" best practice into usual clinical routines. Add in Geisinger, Mayo, Kaiser Permanente, and the Cleveland Clinic, and you have the avant-garde of health systems thinking in America.

Rudolf Virchow and social medicine

2009-10-26T15:38:00.000-04:00

Some random history for today:

I always thought Rudolf Virchow was an interesting physician. Granted he didn't believe in Darwinism or antisceptics, but he did have a great faith in medicine as a tool to lift the condition of communities. Virchow is credited with the founding of "social medicine" positing that disease is never purely biological, but often, socially derived.

I came across this page of his quotes and especially liked this one:

"Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution."

I leave it to you to determine this quote's modern day significance.

U.S. Health Care Reform Interactive Timeline

2009-10-22T11:17:00.000-04:00

Noticed this on NEJM today - neat little interactive graphic on the history of health care reform with links to the relevant NEJM articles from that time.

Health Care Reform 2009 | U.S. Health Care Reform Interactive Timeline

of note, there is an interesting cadence to these efforts - a push for reform, followed by years of stability / status quo - granted you don't want to reform constantly, or too disruptive to system. But regardless, pretty much every other year for the last 50 years a health care bill has been passed.

This American Life series on health care

2009-10-20T11:23:00.000-04:00

If you haven't listened to it already - This American Life has a two part series on health care in the US. Co-produced with NPR/Planet Money group (involved w/ the Baseline Scenario bloggers that I quoted the other day)

This American Life - part one
This American Life - part two

Calvin Trillin’s Theory, the financial crisis and health care mamangement

2009-10-18T19:16:00.000-04:00

Calvin Trillin’s Theory at The Baseline Scenario:

Not directly health care related, but the chart when you follow this link is fantastic. Follow through with me on this and you'll see where I'm going (health care, like finance, has become too complicated for the old guard).

Recent Trillin op-ed recounted a fictional encounter where the interrogator asks what happened on wall st and the interviewee states smart people took over wall street.

"Then, however, as college debts and Wall Street pay grew in tandem, the smart kids started going to Wall Street to make the money, leading to derivatives and securitization, until finally: “When the smart guys started this business of securitizing things that didn’t even exist in the first place, who was running the firms they worked for? Our guys! The lower third of the class! Guys who didn’t have the foggiest notion of what a credit default swap was.”

In the blog link, there's an interesting point about how what's valued in CEO succession, doesn't necessarily lead to a good CEO. "Even when you don’t have the generational issue that Trillin talks about, the problem is that the sociology of corporations leads to a certain kind of CEO, and as corporations become increasingly dependent on complex technology or complex business processes (for example, the kind of data-driven marketing that consumer packaged companies do), you end up with CEOs who don’t understand the key aspects of the companies they are managing."

I wonder if this is an issue in health care. Has health care delivery become so complex, doctors are so disengaged from the process of health care management and reform, that we've slowly gotten ourselves into the current mess that we are in?

I'm really stretching the parallelism here, but I wonder if there is something to it. That's why I guess I'm such a big fan of giving more power to MedPAC - a technocratic body that is independent from politics, and infused with seemingly intelligent and capable health care reform thinkers.

High-Deductible Health Plans

2009-10-16T12:34:00.007-04:00

An article in yesterday’s New York Times discusses the composition and relative merits of high-deductible health plans, which are most often paired with George Bush's favorite cost-containment vehicle, the Health Savings Account. Despite the bitter taste in my mouth when I think about our former president (blech!), I think that high-deductible health insurance plans do have some merit.

First, let's ask ourselves what the point of insurance is. Sounds obvious, but health insurance has metamorphosed into a creature nothing like life insurance or car insurance. In the latter, you pay a premium and if something happens, you first pay a deductible and then, for catastrophic accidents, you get full coverage. Interestingly, having this deductible actually promotes health, sorry car, maintenance activities. After all, you'd rather shell out 20 bucks for an oil change than the 500 dollars for a new transmission down the road - not to mention your car runs smoother in the meantime. Health insurance should really function the same way: you pay premiums and if something really horrible happens, you get totally covered after you surpass the deductible. The way most traditional plans work now, you continue to pay a percentage of costs when your bone marrow transplant costs $1 million, which is why healthcare debt is the leading cause of bankruptcy in the country. Because they cover such unlikely events, high-deductible plans can afford to have cheaper premiums since they make more money on the front end than they lose on the back end.

High deductible plans are meant to reduce the effects of “moral hazard,” which is the notion that people will use more of a good if they are shielded from the costs of consumption. As has been described on these pages, Americans are voracious consumers of healthcare, so perhaps exposing consumers to some of the costs, while not thoroughly penalizing them if something untoward happens, might reduce spending. Alas, health is not like car maintenance, and people have little insight into how health promoting activities may lead to lower financial (not to mention emotional and physical) costs down the road. Because health is so opaque for consumers, they might be willing to defer that colonoscopy if it means they have to shell out $1000 dollars. Furthermore, many of the benefits of health promoting activities wouldn’t accrue to the health plans, but probably to Medicare. Insurance companies, therefore, have no incentive to subsidize “good” behavior now if the beneficiary is the government 20 years from now.

So, this is where the Health Savings account fits in. High-deductible plans paired with HSA's benefit consumers because a) it's a pre-tax contribution and b) employers will often chip in the first $500 to $1000 dollars, and c) HSAs are portable and you never lose what you put in. The HSA is intended to offset the moral hazard problem with high-deductible plans - again, that irrational consumers will avoid costly health promoting activities like skin checks if they have to pay any proportion of that out-of-pocket. Contributing to the HSA is purely voluntary, though, and I suspect those who are trying to save money aren't likely to build a battle-chest of money in case they get sick.

From a pure economics standpoint, these plans make sense. For them to work for everyone, though, I think policy makers have to force insurers to provide basic stuff like checkups, Pap smears, mammograms, etc. for very low or even free prices.

Challenging the Assumption that Costs Always Rise

2009-10-14T03:00:00.002-04:00

In this week's New England Journal, David Cutler, an economist and adviser to the White House, lays out a pretty solid argument for why costs might not rise in the future, even without health payment reform. Our prevailing assumption has been that health care costs will continue to rise, at a pace faster than GDP, until health care bankrupts the nation.

Cutler contends this might not be true based on three core ideas:
1) Technology: the rapid rise in health care costs over the past 10 years has been largely fueled by innovations in pharmaceuticals and medical devices. Cutler points out that the pipeline for new technologies is starting to dry up, and increasing imaging costs might be mitigated by imaging benefit managers akin to pharmacy benefit managers. A formulary for how to diagnose knee pain might not be far off. Further, he notes, profitable new technologies tend to draw lots of competitors, so cost growth is likely to be offset by increased substitution effects.
2) Health IT: Obama's plan to increase spending on EMR's and decision support may cut out huge amounts of wasted time in paperwork and administration, not to mention cut costs from duplicated diagnostic testing.
3) Chronic Disease Management: this one's a little trickier for me (see Sree's last post), but Cutler suggests that by improving disease management, we prevent readmissions and therefore reduce acute care costs. Whether these savings are offset by increased life expectancy is yet to be determined.

Overall, I found this article pretty well researched and thought out and I'm reassured that our Doomsday scenarios might not come to pass. That said, I'm kind of glad it looks like health care spend is on the uptick, because it means policymakers are more likely to pass substantial health care reform in the near term.

Primary care and the health care cost curve

2009-10-13T22:30:00.002-04:00

Guys, I need to submit a blog post to policy2.org to kick start a conversation amongst policy makers and academics on the role of primary care in health reform. Specific question I was asked to answer was "how does primary care bend the cost curve". This is my response - can you give me some feedback in the next 18hrs? Argument flow is weak at points. Doesn't need to win any awards - just start conversation. Need to submit by end of work day tomorrow:

------

Expanding primary care will not bend the cost curve.

All primary care doctors do is postpone thetime of eventual death. The patient lives longer and ultimately develops new and more costly diseasesthat are the consequences of aging.

Ever heard these arguments? I have and it’s fascinating. Intuitively, this makes sense to me. In the cold calculus of economics, good primary care will prevent disease and extend life. As they say, taxes and death are both inevitable. And death costs money, and I have to believe death when you are older is more costly than death when you are slightly younger.

I’m making two huge sweeping assumptions here. First - Primary care saves lives. Second – Death when you are older costs more money to the system. I did a quick literature search to challenge these assumptions.

So let’s question the first assumption – does primary care save lives?

Mackinko et al.did an interesting little interesting literature review in the International Journal of Health Services in 2007. They pooled together a series of studies, re-cut the data in order to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. What they found was interesting - Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. Pooled results for all-cause mortality suggested that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year. Not bad.

I am assuming this is not surprising. Primary care physicians include family medicine doctors, internists,pediatricians, and in some instances, obstetrician–gynecologists. Currently,primary care accounts for about one third of the physician workforce in America. For many, primary care physicians are the first contact for a person with an undiagnosed health concern, they provide patients with the opportunities to prevent disease and they offer continuity and coordination of care for many complex conditions. Given their pivotal role in delivering care, it follows reasonably that they will save lives.

Now the second question – does primary care save money?

This is the tricky one. But one of my favorite studies on this question is from Lubitz et al. from his New England Journal article entitled “Health, Life Expectancy, and Health Care Spending among the Elderly” in 2003. They found that elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about $136,000 (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about $145,000.

Goetzel had an interesting framing of this question in his 2009 Health Affairs article: “Providing certainpreventive services, mostly in clinical settings, does not savemoney. But, then again, neither do most medical treatments.The issue relevant to this debate is how much value is achievedfor any given preventive or treatment service. Instead of debatingwhether prevention or treatment saves money, we should determinethe most cost-effective ways to achieve improved populationhealth, and where to focus scarce resources to get the "biggestbang for the buck."

Note that I did not ask “does prevention save money?” If asked, I’m not sure I could defend the assertion that “prevention saves money.” For example, screening costs can exceed the cost of treatment if only a small portion of a population would get sick without any preventative services. As a society, it might be cheaper to simply treat, and not always prevent.

The question I asked, however, was “does primary care save money?” The role of the primary care physician is not just prevention. Not to be heavy-handed, but I do believe they are the guardians of health – they help the patient navigate the complex decisions of life and health – of prevention and treatment. I believe this is how the primary care physician helps control costs – by helping patients make rational decisions about their care, and providing the longest and healthiest life as possible.

These are just some quick thought starters. I now hand the conversation over to you. I encourage you to use Policy2.org to more fully engage each other, challenge and explore the data, and construct the story that helps us tell the American people that primary care physicians play a vital role in creating a healthier country with greater economic opportunity for all.

Lobbyists Pull the Teeth out of Health Care Reform

2009-10-11T06:30:00.005-04:00

An article in today's New York Times describes the frantic efforts of lobbyists to limit payment reform and hinder policymakers efforts to curb the spiraling cost of health care.

One of the most obvious reforms that's been proposed would be to tax high cost health plans which fuel rising costs because employers are more willing to accept higher premiums when they're tax free. Employees, generally unaware of the cost of health insurance, remain in the dark about what their employers are paying and therefore have no incentive to limit costs themselves. Congress has appropriately considered taxing so-called "Cadillac" plans in an effort to direct employers to purchase less costly health insurance plans and expose consumers to more of the costs. Naturally this check on rising costs is being challenged by the interests that have the most to lose - hospitals, doctors, and insurance companies. Ironically, big-labor has also opposed the reforms even though it would mean employers may pass on the savings in the form of increased wages. The CBO has given this initiative high marks in terms of cost-saving, yet lobbying efforts threaten to kill this part of the bill in committee.

The second major reform is to set up a non-partisan independent Medicare Commission, which seems a lot like the NICE in the UK. The commission would finally leverage Medicare's significant purchasing power to negotiate prices for drugs and negotiate lower costs with hospitals. Drug companies have negotiated only $80 billion in cost reductions over 10 years, which not only represents a drop in the bucket in terms of overall profits, but actually protects them in the long run. By agreeing to small losses, they would actually be protected from further cuts by the Medicare Commission even if five years from now there are major benefits to be extracted. Likewise, hospitals and the AMA are vigorously opposing the $155 billion in reductions to hospital and physician payments even though bloated, inefficient, and often profitable groups working essentially in a cost-plus environment currently have no incentive to limit their costs. What's left? Pilot programs in coordinated care, health IT, and comparative effectiveness (which get seriously dinged by the CBO).

This is just sad, and it's not just Republicans - Democrats in the House are being maneuvered, too. The Baucus bill that represents the only real change in the status quo is being so ticky-tacked that it's going to come out totally ineffective. I understand the need to pass something with some sort of bipartisan appeal, but what's the point if it can't effect any real change? The fact that our political process can't put together something that benefits citizens instead of the influential people that fund campaigns is absolutely pathetic.

Death of Wyden-Bennett

2009-10-09T09:02:00.000-04:00

Jeff Greenberg first turned my attention to the Wyden-Bennett bill - and after reading it, I always thought it was a very good proposal for health care reform. David Brooks actually has a v. good op-ed piece today on the Baucus bill and Wyden/Bennett

Op-Ed Columnist - The Baucus Conundrum - NYTimes.com

More of a description on W/B is in the link from Brooks. But essentially one of my main concerns with the current insurance market and reasons to support W/B is the following:

1) Insurance in America is tied to employment
2) Most Americans switch jobs every few years (~5-15 jobs lifetime)
3) This in turn means that Americans switch their insurance company every few years (in the past decade I have switched insurance companies three times, average time with an insurance company is ~3-7yrs)
4) Insurance companies have little incentive to try to promote health preventative behaviors since all that benefit would accrue to another insurance company, and ultimately Medicare (where we will all get our insurance from eventually).
5) If you decouple insurance from employment and create an insurance exchange market (key elements of W/B), then insurance companies are more likely to have customers for a longer time, thus create sane products that promote healthy behaviors so they can accrue some of the cost benefit (while improving the lives of their customers)

Unfortunately, it seems the W/B is a no-go. And the question remains - to support Baucus bill or not...

NEJM -- The Cost of Health Care -- interviews by Atul Gawande

2009-10-08T10:34:00.000-04:00

Worth a scan. Gawande interviewing academics on health reform from New England Journal of Medicine this week -

NEJM -- The Cost of Health Care -- Highlights from a Discussion about Economics and Reform

Primary care shortage in the setting of expanding access

2009-10-06T10:10:00.000-04:00

I was recently asked to comment for the Hope Street Group on what impact primary care would experience from expanding insurance access. There was an NY Times article about the Massachusetts reform effort.

In Massachusetts, Universal Coverage Strains Care - New York Times

Here was the initial outline I jotted:

Our nation faces an unprecedented primary care shortage with or without reform

Increasing health coverage for the uninsured could rapidly increase the future primary care supply gap from ~12k PCP-equivalent FTEs to ~29-68k PCP-equivalent FTEs by 2015 (equivalent to a 10-25% increase in today’s supply), and will add particular strains to the primary care system
Even in the absence of reform, a shortage of ~12k FTEs (equivalent to a 5% increase in current supply) is projected by 2015
To serve the 56 M projected uninsured in 2015, 17-56k additional FTEs would be needed, with additional strains on the system due to the unique demands of the uninsured

Primary care shortages are driven by mismatches in supply and demand that are not immediately addressable through market forces

Demand drivers include

Total population growth
Aging population
Growing prevalence of chronic conditions

Supply decreasing due to

Difficult to ramp up supply: Requires 7 yrs of postgrad training before entering health system
Compensation gap: Specialists paid 2-3 times more than PCPs
Difficult to control lifestyle: desire for more “controllable lifestyle” with -2% YoY decline in family medicine residency entrants

The case study of Massachusetts health reform provides key lessons to keep in mind – in particular, the critical need to address the initial demand surge as the newly insured enter the system, the risk of a “downward spiral” as PCPs become overstretched, and the need for transitional assistance to underserved areas
The uninsured demand on primary care has specific implications – it will exacerbate the issue of underserved areas, and it will require a geographic redistribution of resources and an immediate surge in PC supply as the newly insured enter the system

Cost Savings at the End of Life - can primary care make a difference?

2009-10-05T09:44:00.000-04:00

I was recently asked to comment on what effect does "end of life" care have on the rise of health care costs in the US. probably the most relevant article that E. Emanuel (in White House currently) wrote a decade ago.

JAMA -- Abstract: Cost Savings at the End of Life: What Do the Data Show?, June 26, 1996, Emanuel 275 (24): 1907

My thoughts are below:

1) There is nothing inherently wrong with spending a majority of your money for inpatient care in the last years of life. The more appropriate questions are 1) is the percentage of money spent the right percentage of money overall spent and 2) is the rate of inflation for end of life costs in line or out of line with other expenditures.

When you look at the work that the McKinsey Global Institute did, we found that the major driver of health care cost inflation was outpatient delivery of care - not inpatient care.

2) Outpatient medicine accounts for more than 40 percent of overall health care spending and 68 percent of spending above expected compared to other OECD countries. This category expanded at 7.5 percent per annum from 2003 to 2006—a faster pace of growth than observed in any other cost category—to add more than $166 billion in costs during this period.

3) Inpatient care costs account for 25 percent of overall health care spending but only 6 percent of total spending above expected ($40 billion). This category grew by 6.0 percent annually (trailing GDP growth), or $73 billion, from 2003 to 2006.

End of life issues are tricky - they raise a lot of emotions. But if we look at this purely from a data perspective, the heart of the cost problem is in outpatient care. So yes, you could argue that there is an imperative to reform end of life care since they consume a majority of costs on the inpatient side. But the elderly (=Medicare) spend a large portion of their medical lives admitted in the hospital. And that's okay, in my opinion. If our goal is to bend the cost curve, we should focus on outpatient, not inpatient, care.

Can primary care help reduce the inpatient end of life care costs? I think so - I don't know the data as well. But my hypothesis would be that 1) people at end of life do not make rational informed choices about the care they wish to receive (living wills, care directives, durable power of attorney) and thus 2) they receive more care than they would have wished, but they are too sick to express their views (e.g. stroke patient on life support who would not have wanted to have been on life support). If primary care could provide greater information about what options are available at end of life, people could make more informed decisions. This is what the whole "death panel" issue was about. If these policies could be promoted in a way that ensures a means for patients to exercise their autonomy on end of life issues and are not coerced, then to me this obviously makes sense.

Smooth and Predictable Aid for Health

2009-10-02T11:27:00.000-04:00

I just read this fairly interesting article on global health financing.

Smooth and Predictable Aid for Health: A Role for Innovative Financing? - Brookings Institution

The paper's thesis is that financial aid flow to developing world health sectors are volatile - the terms of making and delivering future commitments of financial aid from donors to donor recipient is uncertain, and therefore makes it poorly suited to fund recurrent health care costs. In english - Cameroon might get $120M one year in aid and $20M in aid the next year, making it hard to know when to buy vaccines, when to invest in human capital, etc - without a predictable flow, health ministers have a hard time allocating funds to projects to ensure they are sustainable.

Another interesting observation in the paper is that when external aid falls in a country, internal expenditures in health fall to an even greater extent. For example - if external aid falls 10%, the country's government will spend 15% less of its own budget on health than the previous year.

The paper argues that there are opportunities to use interesting financial vehicles to smotth out aid flos to make them more predictable. The author suggests that the potential (1) smoothing of irregular aid commitments through securitization of aid receivables; (2) health endowment funds; (3) a swing donor facility; and (4) a “health debit card” for financing shortfalls.

Financial tools have become increasingly sophisticated, and I like the idea of securitizing and creating financial cushions that can help smooth aid flows for countries that have reliable financial and health track records. This is happening already, but I have to imagine not as much as could happen to prevent these unfortunate consequences.

Thai HIV Vaccine Trial Results are Mixed at Best

2009-10-01T10:31:00.002-04:00

The huge NIH/Army HIV vaccine trial using the combination of two previously failed vaccines reported its results last week. The findings were in some ways very encouraging - there was a 1/3 reduction in new HIV cases in the group that received the vaccine when compared to the group that didn't. That said, the numbers were very very small with a three year incidence of 0.925% in the control group versus 0.6375% in the group that received the vaccine. With such small numbers, as some critics have pointed out, a tiny amount of statistical fling could have easily made this trial a total waste of $105 million of US taxpayers money. Not to mention, in terms of biology, there was no difference in terms of viral load in the two groups (suggesting that the vaccine didn't really boost immunity in any significant way). Finally, most vaccines result in at least an 80% reduction in incidence before people will spread them widely.

I wonder why they would have even done this trial in the first place. That is, who would have even thought this could have worked? Granted, the two vaccines were working in different ways, but to invest such huge sums of money when there was little likelihood of a real impact seems very short sighted. I suppose the international community so hungry for a breakthrough therapy for HIV, they'll pretty much fund anything...

Swiss Model for Health Care Is Gaining Admirers - NYTimes.com

2009-10-01T09:54:00.000-04:00

I always find these comparisons misinformed. How can you compare a small country w/ a relatively homogenous population (ethnically and by gini coefficient of income distribution) with a country as diverse as the US?

Swiss Model for Health Care Is Gaining Admirers - NYTimes.com

In my opinion, the right comparisons are the NHS, France, Germany.

Walgreen to the Tamiflu Rescue

2009-09-23T16:46:00.000-04:00

I thought this was an interesting piece on pvt sector intervention for a public health issue. Profit motive for sure, but seems like everyone wins in this. Would love to see the assumptions in the business plan for this piece:

Walgreen to the Tamiflu Rescue | The Market Update | Financial Articles & Investing News | TheStreet.com

The drugstore said it is prepared to compound Tamiflu capsules into the liquid form to produce its Oral Suspension prescription, usually given to children.

Roche, maker of Tamiflu, which is used to fight the flu, said that while the Oral Suspension is in short supply, there exists a stable stock of capsules.

The news fits well within the recent trend for drugstrores, namely that Walgreen, along with other drugstores, such as Rite Aid and CVS Caremark , has been taking advantage of flu season. The three chains are offering seasonal flu shots earlier than in years past, to meet heightened demand.

Digital Health Records: The Hard Road Ahead

2009-09-10T19:45:00.000-04:00

Steve Lohr's writing on EMRs for the NY Times is getting better.

He's the first lay press writer I've seen who actually segments the market. He understands that the drivers for EMR adoption are different for small vs. large offices.

Digital Health Records: The Hard Road Ahead - Bits Blog - NYTimes.com

As I've said before, free is not cheap enough for EMR adoption, especially in small physician offices. PMS (practice management software) reduces your working capital needs, but EMRs are just a huge fixed cost plus large yearly variable costs on maintenance / upgrades.

What's in the senate finance bill?

2009-09-09T09:28:00.000-04:00

Tonight's Obama's big night for health care:

News Analysis - Despite Fears, Health Care Overhaul Is Moving Ahead - NYTimes.com

The senate finance committee is pushing forward with their bill. Below is a detailed summary of key policies in it. I will comment on the policies over the course of the upcoming weeks.

1. Insurance market reforms (beginning Jan 1, 2013)
- Guaranteed issue in individual and small group markets; no pre-existing condition exclusions or rescissions.
- Premiums in individual and small group markets can vary by up to 7.5:1, depending only on age, tobacco use and family composition.
- Individuals with current non-group coverage can 'grandfather' such coverage and avoid new mandates
- Mechanisms for risk adjustment, reinsurance and risk corridors will be included
- Interstate sale of insurance (starting 2015) through creation of "health care choice compacts" in non-group market
- State health insurance exchanges, to which individuals, micro and small group will have access
- 4 actuarial benefit categories (Bronze = 65%; Silver = 73%, Gold = 81% and Platinum = 90%) with a separate "young invincibles" policy for young adults who desire less expensive catastrophic coverage
- Benefit minimums: preventive and primary care, physician services, outpatient, ER, hospitalization, diagnostic imaging/screenings, maternity and newborn, pediatric services (incl. dental/vision), medical/surgical care, Rx drugs, radiation, chemotherapy, mental health and substance abuse services
- No annual or lifetime caps on benefits

2. Ensuring affordable coverage (subsidies)
- Sliding scale tax credits (subsidies) to families between 100-300% FPL. Max premium out-of-pocket for FPL<100 is 3% and for FPL<300% is 13%. Tax credits are tied to silver plan.
- Cost-sharing assistance available to those between 100-300%

3. Shared responsibility (mandates)
- Beginning in 2013, all US citizens and legal residents required to have health insurance or pay penalty (max family penalty is $1500 for FPL 100-300% and $3800 for FPL>$3800) (exemptions for those in which lowest cost premiums exceed 10% of person's income)
- Employers with FTE >50 must either offer insurance or pay a free rider penalty set equal to the value of the tax credit for each employee taking up insurance on the exchange

4. Health care cooperatives
- Federal loans to assist in start-up costs for nonprofit, member-run health insurance companies to ensure at least one co-op in every state

5. Medicaid expansion and CHIP reform
- Starting Jan 1, 2014, Medicaid must cover everyone, including childless adults, up to 133% FPL
- States must maintain existing income eligibility levels for all populations until state-based exchanges become operational
- Additional federal assistance to help cover costs of new Medicaid eligibles
- CHIP beneficiaries moved into exchange in 2013 and states provide a "CHIP-wrap" to provide supplementary benefits required under CHIP
- Federal floor for CHIP eligibility is FPL 250%
- Rx drug becomes mandatory Medicaid benefit
- Medicaid Rx drug rebates would apply to Medicaid managed care orgs and increase from 15.1% to 23.1%
- DSH payments reduced 50% once uninsured population in a state is reduced by 50%. Further reductions correspond with decrease in rate of uninsured. to a max reduction of 65% relative to 2012 allotment

6. Improving quality and efficiency
- Value-based purchasing in Medicare starting 2011 for:
- hospitals which ties percentage of hospital payment to performance on key quality measures
- Physicians, especially with respect to high-cost imaging services
- Medicare home health agency and skilled nursing facilities
- New patient care models
- Accountable care organizations in which provider groups can keep half of savings they achieve for Medicare program over 3-yr period
- Voluntary pilot program on payment bundling
- Hospital payment penalties for hospitals with top 25% of high-cost commonly acquired hospital infections
- Payment reductions for hospital readmissions in excess of certain benchmark
- Strengthening primary care through extra incentives/payments in shortage areas and increasing residency slots in primary care
- Scheduled 21% reduction in Medicare physician payment rates in 2010 would be replaced with 0.5% increase
- Reimbursement adjustments to Medicare physician fee schedule

7. Medicare Advantage (MA)
- Re-set of MA benchmarks based on weighted average of plan bids beginning in 2014. Plans keep 100% of difference between bid and new benchmark

8. Independent Medicare commissions
- Congress would have to pass an alternative proposal that yielded equivalent budget savings or commission payment recommendations would go into effect

9. Revenue provisions
- High cost insurance excise tax of 35% levied on insurance companies and insurance administrators of any plan that is above $8000 for singles and $21,000 for families. The tax would apply to self-insured plans and plans sold in group market, but not to individual plans. Tax would apply to the amount of premium in excess of threshold, which would be indexed for inflation, and could be increased for high-cost states
- New nonprofit hospital requirements that would include a periodic community needs assessment
- Pharmaceutical manufacturing companies fee of $2.3 billion per year, starting 2010, allocated by market share
- Med Device manufacturers fee of $4 billion per year, starting 2010, allocated by market share
- Health insurance provider fee of $6 billion per year, starting 2010, allocated by market share
- Clinical laboratories fees of $750 million per year, starting 2010, allocated by market share, except for small businesses

Helene Gayle to advise Obama on AIDS | Reuters

2009-09-04T12:27:00.001-04:00

I don't think this is the same position that Paul Farmer was up for - I think he was under consideration for USAID - and I heard a lot of his writing was of concern with the Senate.

Anyways, Celine I know you are in touch w/ Helene. It is advisory, so I'm not sure how much sway on actual policy the panel will have, but regardless, very exciting.

Helene Gayle to advise Obama on AIDS | Reuters

Gang of Six seems to be dying

2009-09-01T11:45:00.000-04:00

Montana Senator Max Baucus, the head of the Senate Finance Committee, said on Monday that health-care reform will pass this year, even if Republicans back out of bipartisan negotiations. This matters because Baucus is the head of the so-called Gang of Six—three Democratic and three Republican senators who have been negotiating over the bill.
Until recently, the White House has not remarked on any of the " Gang of Six ", but The White House press secretary Robert Gibbs recently slammed Senator Mike Enzi after he used the GOP’s weekly radio address to attack health care.

Baucus predicts health care overhaul this year

All of this makes it seem like the Dems are going to go this alone - without even their own moderate Dems - which honestly puts the public option back on the table.

CIA documents reveal close involvement of physicians in developing torture techniques

2009-08-26T11:08:00.000-04:00

I honestly just can not understand what would drive a physician to have absolutely any part in torture. Jeff had blogged about this before, but this article raised the issue again. It is just atrocious.

Article in today's NYT -

Report Shows Tight C.I.A. Control on Interrogations - NYTimes.com:

From the intro:
"A prisoner could be doused with 41-degree water but for only 20 minutes at a stretch.... another detainee repeatedly knocked out with pressure applied to the carotid artery."

"Managers, doctors and lawyers not only set the program’s parameters but dictated every facet of a detainee’s daily routine, monitoring interrogations on an hour-by-hour basis. From their Washington offices, they obsessed over the smallest details: the number of calories a prisoner consumed daily (1,500); the number of hours he could be kept in a box (eight hours for the large box, two hours for the small one); the proper time when his enforced nudity should be ended and his clothes returned."

Later in the article:

"Waterboarding might be an excruciating procedure with deep roots in the history of torture, but for the C.I.A.’s Office of Medical Services, recordkeeping for each session of near-drowning was critical. “In order to best inform future medical judgments and recommendations, it is important that every application of the waterboard be thoroughly documented,” said medical guidelines prepared for the interrogators in December 2004.

The required records, the medical supervisors said, included “how long each application (and the entire procedure) lasted, how much water was used in the process (realizing that much splashes off), how exactly the water was applied, if a seal was achieved, if the naso- or oropharynx was filled, what sort of volume was expelled, how long was the break between applications, and how the subject looked between each treatment.”

When the doctors gauged what a drenching in a cold cell might do to a prisoner, they did their research, consulting a textbook entitled “Wilderness Medicine,” in particular Chapter 6 on “accidental hypothermia,” as well as a Canadian government pamphlet, “Survival in Cold Waters,” according to footnotes.

A Cure for Doctors' Bills

2009-08-17T21:45:00.000-04:00

Was reading this article and what struck me is how relevant many parts of the discussion are still today.

A Cure for Doctors' Bills - The Atlantic

This article is from the atlantic from 1930. As a colleague of mine said - no matter what happens over the next few months, there will always be a need for health reform for ages to come.

---

"The high costs of medical care are not only the subject of countless articles in the public prints, but are even being discussed in the inner circles of the profession...

The medical profession itself has now seen the writing on the wall. Something must be done. In Europe the drift is toward state medicine. In this country, too, there is a definite set of opinion in that direction. At the annual meeting of the American Medical Association held in Detroit in June, the retiring president of the association told the house of delegates that socialization of medicine, along lines now suggested in England, was inevitable, unless the American physicians themselves established medical centres to enable the poor and the ‘white-collar classes’ to cope with the mounting cost of living.

‘Medicine,’ he said, ‘is being besieged on every side by forces that are constantly growing stronger and stronger, and unless some defensive effort is made to break the siege, the profession must eventually capitulate, become socialized, and become employees of the State.’

Most American doctors look upon any such solution with dismay. The medical journals are full of protestations against the threatened loss of the doctor’s professional independence. State medicine is their special bête noire."

"How American Health Care Killed My Father" in The Atlantic

2009-08-15T20:47:00.000-04:00

http://www.theatlantic.com/doc/200909/health-care

A Primer on the Details of Health Care Reform

2009-08-10T12:46:00.000-04:00

Haven't muddled through this yet, but imagine it is similar to the KFF post from the other day comparing proposals

A Primer on the Details of Health Care Reform - NYTimes.com

Health Debate Turns Hostile at Town Hall Meetings

2009-08-08T13:41:00.000-04:00

Health Debate Turns Hostile at Town Hall Meetings - NYTimes.com

if it is any secret, this - to my understanding - is one of the main reasons that the WH wanted to pass health care reform prior to august recess.

will be interesting to see how legislators are influenced by these mobs - which seem to be more "brooks brothers brigade" than real populist uprisings.

worrisome, for sure.

Clinical trial recruitment challenges

2009-08-04T11:17:00.000-04:00

Recent nytimes article on challenges of clinical trial recruitment (CTR).

Forty Years' War - Lack of Study Volunteers Hobbles Cancer Fight - Series - NYTimes.com

This is a cut on the challenges of CTR that I hadn't thought of before - the factoid that a patient has to spend 196 eight hour work days over the course of five years is unbelievable - that's two months of work a year you're committed to the trial. Most of the pharma conversation is about just trying to find the patients or the step prior - clinical trial feasibility(can we even find enough patients to do this trial) - but less around the challenges to a trial participant.

Interesting piece. More thoughts soon -

Sermo CEO on a mission...

2009-07-29T12:25:00.000-04:00

The CEO of Sermo - a leading online community for physicians is now in a fight with the AMA and Doctors for America - an organization run by some friends of ours supporting the Obama health care reform effort.

Details at
Sermo CEO: AMA 'screwing' physicians - Modern Medicine Community Blog post and at the bottom of this email (a facebook message from DFA)

An interesting point raised in the first article is that the AMA receives a lot of money for the CPT coding system - a fact I did not know about:

"The AMA receives approximately $70 million in 'licensing fees' from anyone who needs to use those codes. Add to that insurance companies (who pay the AMA many of those millions) who can use the CPT coding system to further their own gains at the expense of the physicians, and it starts to make you realize why CPT codes have been so conveniently left out of the current debate."

The CEO of Sermo also supposedly went onto CNBC early this week saying that physicians opposed health care reform based on a survey they did on their online community.

I had blogged about this survery earlier this month. It seems spurious at best, though I agree with the general premise that the AMA does not speak for all physicians. However, I'm not sure what the motivation is for the CEO of Sermo - is he trying to supplant the AMA as the "voice of physicians"? It all seems like a bizarre sideshow about doctor power instead of the real debates on health care reform.

---

From DFA on facebook:

Dear Friends,

(If you haven't already, come be a fan of our Facebook Page: http://www.facebook.com/pages/Doctors-for-America/94559877688?ref=ts for updates on the latest in health reform and other fun.)

The CEO of Sermo plans to announce on national television that doctors oppose health reform legislation.

**Don't let him speak for you. Click to take our quick poll today!**
(www.drsforamerica.org/pol

l/house.php)

The claim is based on a misleading survey of Sermo members. It will be unveiled on Monday, July 27th on CNBC and shared with Congress. However, we know from the comments and actions of thousands of fellow physicians across the country that doctors want and need health reform this year.

**Do you have 2 minutes? Help us tell the truth about reform today!**
(www.drsforamerica.org/poll/house.php)

Doctors are the most trusted voice in health reform - you can make the difference. Just this past week, Doctors for America members in 30 states picked up their phones to call Congress in support of reform, and physicians from Kansas to Wyoming, from Alaska to New Mexico, have signed up to volunteer. You can help today with a quick poll on whether you like various aspects of the reform bill.

**Answer this quick poll today!**
(www.drsforamerica.org/poll/house.php)

After you have voted, please send this link to 5 friends. We will give preliminary results to CNBC and other media early Monday morning. We have made great progress toward achieving meaningful health reform, but those gains are only temporary until reform legislation lands on the President's desk. We need to do everything we can to help make sure we have good reform and that it passes this year. I know we can count on you.

Thanks,
Alice

Side-by-Side Comparison of Major Health Care Reform Proposals by the Kaiser Family Foundation

2009-07-28T15:50:00.000-04:00

This link contains an interesting tool that allows Side-by-Side Comparison of Major Health Care Reform Proposals.
It is from the Kaiser Family Foundation.

"Achieving comprehensive health reform has emerged as a leading priority of the President and Congress. President Obama has outlined eight principles for health reform, seeking to address not only the 45 million people who lack health insurance, but also rising health care costs and lack of quality. In Congress, a number of comprehensive reform proposals have been announced as the debate proceeds over how to overhaul the health care system.

This interactive side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by-side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as draft proposals or as policy options. This side-by-side offers a summary of the major components of these proposals; detailed descriptions of provisions relating to the Medicare and Medicaid programs can be found online. It will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced."

ACP moving towards endorsing health care reform

2009-07-27T14:03:00.002-04:00

We have talked previously about our frustrating with the American Medical Association (AMA). Many physicians do not believe that the AMA speaks "on their behalf."

On the other hand, most physicians place more stock in their respective specialty association. Since medicine is so diverse, the support needs are highly specialized by specialty and these associations cater specifically to the specialties needs. As an internist, I'm more keen to see what my association - the American College of Physicians (ACP) - has to say on the matter.

I received an email from my local ACP president which is fairly supportive of the current House bill. I'm not really following closely what the AMA has to say on the bill, but I'm glad to see that the ACP is thinking about the legislative process in a sane manner.

The last two paragraphs of this post I think are the constructive message for physicians - be a part of the process, instead of vilifying ourselves - and let's try to make this reform effort a step in the right direction.

-----

TO: ACP Key Congressional Contacts

FROM: Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy

SUBJECT: ACP's views on H.R. 3200, the America's Affordable Health Choices Act of 2009, and efforts to organize opposition to it

Yesterday, the chairmen of the three House committees with jurisdiction over health care reform introduced the America's Affordable Health Choices Act of 2009, H.R. 3200. (The Senate Health, Education, Labor and Pensions Committee has introduced its bill; we are still awaiting a bill from the Senate Finance Committee, which may be released within days). I want to update you on why the American College of Physicians believes that H.R. 3200 merits internists' support, even as we continue to work for improvements through the legislative process.

I know this e-mail is long, but I encourage you to take the time to read through it. It is critical that we continue to work together as Congress moves forward on legislation so critical to patients and you, the physicians who care for them.

The bill is closely aligned and consistent with ACP policies on our top priorities for health reform as developed through our policy committees and approved by the Board of Regents (with input from the Board of Governors and ACP councils). Specifically:

Coverage: The bill creates a pluralistic framework so that all Americans will have access to affordable health insurance coverage, similar to ACP's own seven year plan. It will give eligible persons a wide choice of health plans, including the option of maintaining their current health plan. ACP supports the bill's proposals to reform the insurance industry so that coverage no longer is out of reach for people who have pre-existing conditions or who develop an illness while insured. We support sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor.

ACP does not have policy on the bill's proposal to finance coverage through an income tax surcharge on higher income persons. I anticipate, though, that there will be major changes in the tax and financing mechanisms as legislation makes its way through the House and then has to be reconciled with the Senate, which seems disinclined to rely on an income tax surcharge. The College supports the bill's shared responsibility for funding health care reform, including requirements that employers contribute to coverage and that individuals obtain coverage once affordable options are available to them.

Workforce: The bill would establish a national health workforce policy to help set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians. It includes policies, recommended in ACP's own policy paper on solutions to the primary care workforce crisis, to increase the numbers of physicians in primary care internal medicine, family medicine and geriatrics, including increased funding and creation of new pathways to provide scholarships and loan forgiveness to primary care physicians who agree to practice in areas of need and policies to facilitate increased training in office-based primary care practices. We also agree on the need to increase GME training positions for primary care specialties as the bill proposes.

Sustainable Growth Rate: The bill would eliminate the accumulated Medicare SGR payment cuts, and by doing so, pave the way for Congress to replace the annual cycle of Medicare payment cuts with a new update system. The bill provides a new framework for future updates that allow for spending on physician services to increase at a rate greater than GDP, and creates a higher spending baseline target for evaluation and management and preventive services, including those associated with primary care.

Primary Care Payment Increases: The bill provides for an additional 5% increase, beginning in 2011, for designated evaluation and management services by general internists and other primary care physicians. The primary care bonus is increased to 10% for designated services in Health Professional Shortage Areas. The bill also would increase Medicaid payments for primary care to be equivalent to Medicare.

Although ACP continues to believe that a larger primary care bonus is needed-we have asked for at least 10% in all areas the country, 15% in health professional shortage areas, we believe that the recognition of the need to increase payments for primary care is an important step forward, especially combined with other changes in the bill to support primary care.

Patient-Centered Medical Home: The bill also provides dedicated funding to pilot-test, on a national scale, the idea of paying physicians for care coordination in a qualified Patient-Centered Medical Home. ACP will continue to provide Congress with ideas on strengthening the payment and delivery system reforms to accomplish the goals of increasing the numbers of physicians in primary care fields.

Comparative Effectiveness Research (CER): The College strongly supports the proposal to fund independent, transparent and evidence-based research on the comparative effectiveness of different treatments to inform physician-patient decision-making.

In addition to its strong correlation with ACP policy and priorities, H.R. 3200 provides substantially more funding to physicians at a time when most other providers are facing deep cuts, according to preliminary estimates from the Congressional Budget Office.

$228.5 billion to eliminate accumulated SGR cuts
$1.6 billion for the PQRI (positive incentives only, no penalties for non-reporting)
$1.3 billion to make the geographic floor on Medicare payment permanent
$5 billion for the primary care bonus
$1.8 billion for medical home demonstrations

No bill is perfect, but the House bill delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College's leadership over many years and always guide how we-leadership, Key Contacts and staff-advocate for ACP's internal medicine physicians and your patients.

Despite all of the positive elements in H.R. 3200, there is an effort being made in many states to persuade physicians to oppose the bill. You should be aware of the arguments being made by opponents and how I respond to them:

• Opponents argue that the "public plan option" included in H.R. 3200 would lead to the destruction of private insurance and government-run health care.
This is an issue that has elicited strong but divided opinion among ACP members. Some internists have expressed practical and philosophical concerns about the public plan, while others have said that they believe a public plan is essential.

ACP policy says: a public plan could appropriately be offered, along with qualified private plans, if participation in the public plan is voluntary, if it competes on a level playing field with private insurers, and if it is not locked into Medicare's payment rates. Under H.R. 3200, physician and patient participation in the public plan would be voluntary. The public plan would have to pay for itself through premiums collected, rather than being funded from the U.S. Treasury, to help place it on a level playing field with private insurers.

ACP has advised the House that we are concerned that the House bill would have a public plan use Medicare rates (Medicare plus 5% for physicians who accept both Medicare and the public plan) for its first three years. The College will continue to strongly advocate that the public plan be required to pay competitively with private insurers. (The Senate HELP bill, for instance, would benchmark the public plan's rate to the average offered by qualified private plans, so there will be opportunities to address how the public plan sets its rates later in the legislative process).

Opponents also suggest that H.R. 3200 would prohibit private contracting and balance billing, but there is nothing in the law that prohibit existing rights for physicians and patients to enter into voluntary contracts. Like Medicare, however, physicians who choose to take care of patients in the public plan would have to accept limits on charges, similar to the Medicare participating and non-participating physician agreements. No physician would be mandated to accept the public plan and its rates.

The idea that the public plan would destroy private insurance is also not supported by expert analysis. The Congressional Budget Office notes that because physician participation in the public plan is voluntary, and payments are likely to be lower than payments under private insurance plans, it is difficult to estimate how many people would enroll in the public plan. The CBO suggests that enrollment in a public plan, at full implementation, could be as many as 8 or 9 million people out of the estimated 30 million who would get coverage through the exchange, many of whom though are currently uninsured, but even so, this would mean that most people in the exchange would be covered under private insurance. CBO also estimates that the vast majority of persons-164 million, an increase of two million persons compared to current law-would be covered by employers.

• Opponents argue that CER would lead to rationing of care by government bureaucrats.
Actually, the bill's CER provisions are completely consistent with ACP's support for an independent, transparent and evidence-based process to conduct research on the clinical effectiveness of different treatments to inform clinical decision making. There is nothing in the bill that allows costs to be used to deny care. The research would be conducted by physicians and other scientists in agencies, like the National Institutes of Health and the Agency for Health Care Research and Quality, not by government bureaucrats. Coverage decisions would still be made as they are today, but instead would be informed by the best available clinical evidence instead of by criteria that often is not guided by science.

Now it's time to think politics.

To try to influence Congress to consider our ideas to improve the bill, we will be far more effective if internists support all of the positive policies in the bill. We want to continue to be invited to the table and not to have to fight to be there. Destructive opposition will effectively remove us from being invited and place at great risk all of the positive changes that the bill would bring about -including the coverage, workforce, elimination of Medicare SGR cuts, and payment reforms to support primary care.

To this point, the overwhelming majority of physicians have supported health care reform. Let's stay together and let other stakeholders bloody themselves. We still have the senate bills to work through, votes to seek and a Senate-House conference committee to work with. We need, and hope for, your active participation throughout.

Rationing Health Care (don't we already?)

2009-07-21T08:35:00.002-04:00

Prof. Peter Singer from Princeton University had a great piece on the ethics of rationing health care in Sunday's NYT Magazine.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html

We already ration health care by prioritizing health care delivery for the relatively wealthy.

The question is not whether to ration health care. The question is whether the wealthy are willing to accept rationing of their health care for the general good.

Randomized Controlled Trial Shows Circumcision Does Not Prevent Male-To-Female HIV Transmission - Kaiser Global Health

2009-07-19T18:13:00.000-04:00

Global health folks - what's your thoughts on this recent Lancet article?

Randomized Controlled Trial Shows Circumcision Does Not Prevent Male-To-Female HIV Transmission

I was following the literature about two years ago, and had blogged about this previously. This study I could see be used to detract from circumcision programs - and I find the literature increasingly confusing. What's your take on it?

Collins and Brooks on health care reform

2009-07-16T22:22:00.000-04:00

Partisan Health Care Politics - The Conversation Blog - NYTimes.com

The conversation between Brooks and Collins is right on point. The bills being developed in Congress do not fundamentally shift the incentives in health care. We are cutting prices which really doesn't do anything to change doctor's incentives. If anything, they are more likely to medicalize their patients more... for example, Japan has been trying to control health care costs for the last two decades, and they have used prices as their main lever. Consequently since Revenue = price times quantity, all that Japanese physicians have done is reduce the time they see patients, and see more patients per session (raised quantity since prices are down, to maintain their revenue).

I like what Collins and Brooks argue for - a strong MedPAC that has teeth. Their reports are great - much like NICE in the NHS / UK - but just like NICE, there's no impetus for congress to act on MedPAC ideas.

I'm becoming more of the mind that health care needs strong intelligent technocrats, and not partisans who infuse ideology into difficult policy negotiations. the conversation between collins and brooks highlights that there are many principles that folks from both sides of the aisle can agree on.

Taxing to pay for health care - is it necessary?

2009-07-14T21:43:00.000-04:00

The House Democrats have introduced their proposal for health care reform.

The tax raises are minimal at first:

"Starting in 2011, a family making $500,000 would have to pay $1,500 of additional income tax to help subsidize coverage for the uninsured. A family making $1 million would have to pay $9,000."

This is not a tremendous amount of money. It does have the potential to rise substantially if the government is not able to "bend the cost curve" and decrease Medicare and associated costs.

What I upsets me a bit is that we are even looking at tax raises. Don't get me wrong - I have no issues paying higher taxes - but the fact that we spend over $2 trillion and we have to raise even MORE money for health care seems ridiculous.

The issue in our health care system is about paying for health care value - not paying for more health care regardless if it has value or not. We have discussed Michael Porter's NEJM article previously on this board - but he says it best:

"What we need now is a clear national strategythat sets forth a comprehensive vision for the kind of healthcare system we want to achieve and a path for getting there.The central focus must be on increasing value for patients —the health outcomes achieved per dollar spent. Good outcomesthat are achieved efficiently are the goal, not the false "savings"from cost shifting and restricted services. Indeed, the onlyway to truly contain costs in health care is to improve outcomes:in a value-based system, achieving and maintaining good healthis inherently less costly than dealing with poor health.

True reform will require both moving toward universal insurancecoverage and restructuring the care delivery system. These twocomponents are profoundly interrelated, and both are essential.Achieving universal coverage is crucial not only for fairnessbut also to enable a high-value delivery system. When many peoplelack access to primary and preventive care and cross-subsidiesamong patients create major inefficiencies, high-value careis difficult to achieve. This is a principal reason why countrieswith universal insurance have lower health care spending thanthe United States. However, expanded access without improvedvalue is unsustainable and sure to fail. Even countries withuniversal coverage are facing rapidly rising costs and seriousquality problems; they, too, have a pressing need to restructuredelivery."

And again, this is the issue - cost containment and driving health care value.

Survey on the AMA

2009-07-10T22:29:00.000-04:00

Sermo - an online physician community - recently polled physicians on their opinions on the AMA - a topic we have talked about on this board.

Survey results

The survey results are cut bizarrely. But with that said, taking a few leaps in analytics, it looks like even 50% of the people who are members of the AMA believe the AMA does not speak for them, and only a third of AMA members believe that the AMA accurately reflects their opinions as a physician.

I guess people join for the free JAMA subscription. Not for their lobbying efforts...

New NIH head

2009-07-10T16:58:00.001-04:00

Wanted to forward along the article some of us were discussing at dinner last night.

http://www.nytimes.com/2009/07/09/health/policy/09nih.html?_r=1&ref=health

"There are two basic objections to Dr. Collins. The first is his very public embrace of religion. He wrote a book called “The Language of God,” and he has given many talks and interviews in which he described his conversion to Christianity as a 27-year-old medical student. Religion and genetic research have long had a fraught relationship, and some in the field complain about what they see as Dr. Collins’s evangelism.
The other objection stems from his leadership of the Human Genome Project, which is part of the N.I.H. Although Dr. Collins was widely praised in 2003 when the effort succeeded, the hopes that this discovery would yield an array of promising medical interventions have greatly dimmed, discouraging many. "

IOM and residency work hours

2009-07-10T08:27:00.000-04:00

Recent article on IOM's new work hour suggestions

Report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

They don't reduce the overall number of hours that people work, but by introducing this, you effectively need to double your workstaff because somebody else will need to be around while the other doctor is taking their nap.

I understand the patient safety need - but by introducing siesta into residency training you'll be doubling handoffs (bad for patient care) and you'll need to increase workstaff (drives costs).

Sounds like a bad idea to me.

Dems leaning towards tax increases?

2009-07-09T23:04:00.000-04:00

We all know that our health care system spends nearly double what other developed countries do, leaves many uninsured, and leads to worse outcomes. So the solution that many Democrats are leaning toward is....spending even more money. This is a total failure of leadership. Apparently they are too weak to stand up to key stakeholders - docs, hospitals, payors, pharma, and others - to bring costs under control. So rather than create a sustainable health care system, they will dump more money into it in order to expand it to cover more patients. They are looking to tax the wealthy to do this. I am not against taxing the wealthy per se, but it should not be necessary for health care reform. There is already enough money in the system to cover every man woman and child in this country, if we could spend that money more wisely. But that takes courage, innovation, creativity, and, above all, political will. It means axing or cutting the employer health plan tax deduction, reforming how docs and hospitals are paid, ending the subsidy for Medicare Advantage, funding comparative research - all things that would lead to wiser spending but potentially alienate some powerful interests. Obama needs to step up to the plate and spend some of his political capital to fix the system, rather than expand it.

Krugman on Universal health care

2009-07-06T21:59:00.000-04:00

Op-Ed Columnist - HELP Is on the Way - NYTimes.com: "a look at the U.S. numbers makes it clear that insuring the uninsured shouldn’t cost all that much, for two reasons.

First, the uninsured are disproportionately young adults, whose medical costs tend to be relatively low. The big spending is mainly on the elderly, who are already covered by Medicare.

Second, even now the uninsured receive a considerable (though inadequate) amount of “uncompensated” care, whose costs are passed on to the rest of the population. So the net cost of giving the uninsured explicit coverage is substantially less than it might seem."

A Doctor's Reflections on Health-Care Reform

2009-06-29T21:21:00.000-04:00

It is articles like this - without data, and full of self-interested posturing, that gets me upset about physician perspectives on health care reform.

A Doctor's Reflections on Health-Care Reform - WSJ.com

The McAllen Problem

2009-06-29T20:37:00.000-04:00

Rajiv pointed me to this article the other day - brutally on target, if you ask me. As one of my mentors once told me - doctors are finely tuned economic machines:

The McAllen Problem: The Baseline Scenario

What is the lesson of McAllen, Texas, the focus of Atul Gawande’s celebrated article (discussed here and here)? This is my attempt at an answer:

Currently, our health care system has high-cost and low-cost areas; the high-cost areas have no better outcomes than the low-cost areas. So theoretically we can solve our health care cost problem by making the high-cost areas behave like the low-cost areas.

However, the market incentives go in the other direction; the economically rational thing for providers (doctors, hospitals, etc.) to do is to run up procedures and thereby costs. It would be better if providers focused more on patient outcomes or organized themselves into accountable care organizations, as Gawande prefers; but there is no economic reason for them to do so. People are not magically going to become more altruistic overnight. Even shame has only a temporary effect on behavior. Here’s Gail Wilensky from a Health Affairs roundtable:

It’s only by being able to offer compelling evidence that it’s the physician that is the outlier relative to his or her peers, that the patients really aren’t different, and in fact they are not having better outcomes, that you are able to pull back physician behavior — although there seems to be a high recidivism rate.

(Emphasis added.)

In some ways McAllen isn’t the aberration; according to the old Chicago economics department, everywhere should be like McAllen.

Remember all the people who said that you can’t blame mortgage brokers and investment bankers for being greedy, because that’s how a capitalist economy works? Well, you could make the same defense for the McAllen doctors. We long ago stopped expecting lawyers and accountants to behave contrary to their economic interests; now we simply expect them to conform to the law and to certain professional codes of conduct, and otherwise make as much money as possible. Why should we expect anything different from doctors?

In a capitalist economy, the thing that is supposed to keep prices in check is the buyers. If someone offers me a product that costs more than it is worth to me, then I won’t buy it. But we can’t count on patients to play this role in health care, because there is no way to make patients internalize all of the costs of their care; they simply don’t have the money. Furthermore, most people don’t understand the health production function (the relationship between treatments and outcomes), so they don’t have the ability to select treatments that provide benefits that are worth their costs. (And, in many cases, it’s not obvious even to professionals that a treatment isn’t worth the cost; it’s only obvious when you look at the data in aggregate.)

What about payers (health insurers?) A “market” solution would be to change the reimbursement rates for different procedures – increase payment for things that doctors should do more of and reduce payment for things that doctors should do less of. Theoretically, payers should be doing this already. However, in the current situation, a private payer who tried to reduce the rates for popular, expensive procedures would find itself unable to attract providers. The only payer with any real negotiating power is Medicare. The private payers have little ability to control costs. Or, if they have the ability, they aren’t exercising it.

In short, prices will only go up. As a result, the cost of health insurance goes up, and the market finally kicks in in the crudest possible form: people who can’t afford it become uninsured. At some point, if we have enough uninsured people, the health care industry will hit a point where it cannot increase revenues anymore, because it has fewer and fewer paying customers.

The proposed public health insurance plan would have the power to negotiate lower rates with providers. That’s why some providers don’t like it. That’s also why private payers don’t like it; they would be at a cost disadvantage to the public plan. (They can live with Medicare because Medicare leaves them the entire under-65 market.) Maybe that’s unfair. But the current situation isn’t working.

By James Kwak

The Institute for Health Metrics and Evaluation (IHME)’s upcoming report, "Financing Global Health 2009"

2009-06-25T04:19:00.000-04:00

But 12 of the 30 countries with the highest disease burden aren’t receiving as much aid as healthier, and, in some cases, wealthier countries

–Well-heeled donors, private corporations and average citizens sending money to their favorite charities are changing the landscape of global health funding, according to a new study by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

Press release: http://healthmetricsandevaluation.org/resources/news/2009/Jun_18_2009.html

The Lancet, Volume 373, Issue 9681, Pages 2113 - 2124, 20 June 2009 Financing of global health: tracking development assistance for health from 1990 to 2007 at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60881-3/fulltext

“…..The research shows that funding for health in developing countries has quadrupled over the past two decades – from $5.6 billion in 1990 to $21.8 billion in 2007. Private citizens, private foundations and non-governmental organizations are shifting the paradigm for global health aid away from governments and agencies like the World Bank and the United Nations and making up an increasingly large piece of the health assistance pie – 30% in 2007. However, health aid does not always reach either the poorest or unhealthiest countries.

The study, Financing of global health: tracking development assistance for health from 1990 to 2007, appears in the June 20th issue of The Lancet and provides the first ever comprehensive picture of the total amount of funding going to global health projects. It takes into account funding from aid agencies in 22 developed countries, multilateral institutions like the World Health Organization and hundreds of nonprofit groups and charities. Prior to this report, nearly all private philanthropic giving for health was unaccounted for, meaning that nearly a third of all health aid was not tracked.

Overall, poor countries receive more money than countries with more resources, but there are strong anomalies. Sub-Saharan Africa receives the highest concentration of funding, but some African countries receive less aid than South American countries with lower disease burdens – like Peru and Argentina. Of the 30 low- and middle-income countries with the most illness and premature death, 12 are missing from the list of countries that receive the most health aid, including Angola, Ukraine and Thailand.

"With no one tracking this massive growth in spending, it’s no wonder that some countries receive far more than their neighbors for no immediately apparent reason,” said Dr. Christopher Murray, professor of global health and director of IHME at the University of Washington, and co-author of the study. "We’re hoping that this attempt to count money that has never been counted before in a careful and consistent way will lead to greater transparency and better use of health resources.”Some small island nations with relatively healthy populations like Micronesia and the Solomon Islands receive more health aid per capita than disease-stricken countries like Niger and Burkina Faso. Mali and Colombia have about the same level of sickness, but Colombia receives three times as much health funding. The study also found that two of the world’s emerging economic super powers, China and India, receive huge amounts of health aid. “We don’t know exactly why some countries seem to be far outpacing other countries, but historical, economic and political ties appear to be a factor,” said Nirmala Ravishankar, an IHME research scientist and the study’s lead author. “Some of these small islands are former colonies of the countries now giving them aid, and, in other cases, health aid seems to coincide with defense spending or drug interdiction efforts. This is an area that begs for more research.”

Where the money is being targeted within those countries also merits more scrutiny. Based on the research for 2007, HIV/AIDS receives at least 23 cents out of every dollar going into development assistance for health. Tuberculosis and malaria received less than a third of that, even though the combined burden for those diseases is greater than that from HIV/AIDS in developing countries and despite promises by G8 countries that those diseases would receive more funding. At the same time, about a nickel out of every dollar channeled to health assistance goes to system-wide health support – like funding for new clinics, doctor training and prevention programs – which is an area that global health experts have clearly identified as a priority. The study also reveals other key findings:

The scale-up of global health funding doubled from 1990 to 2001 and then doubled again by 2007.
The growth has been driven largely by donations from the U.S. government and U.S.-based private charitable organizations. In sheer volume, the U.S. accounted for over 50% of total development assistance for health in 2007. But, in terms of the fraction of national income that becomes health aid, the U.S. trails Sweden, Luxembourg, Norway, and Ireland.
The Bill & Melinda Gates Foundation tops the list of private foundations providing global health aid, making up nearly 4% of all health assistance in 2007.
Food For The Poor, Population Services International and MAP International lead all non-governmental organizations (NGOs) in spending on health aid, each contributing more than $1 billion in health assistance from 2002 to 2006. Six of the top 10 NGOs are religious organizations.
In-kind contributions, such as donated drugs, made up more than 90% of the revenues of some of these NGOs, and they made up more than 50% of their total overseas health expenditure for most years during the study period. Because donations of drugs from pharmaceutical companies are sometimes valued at current market prices, this has potentially resulted in an exaggeration of the magnitude of resources flowing via US NGOs.

More details will be published in The Institute for Health Metrics and Evaluation (IHME)’s upcoming report, Financing Global Health 2009, University of Washington, Seattle, WA, USA.

(N Ravishankar PhD, P Gubbins BA, R J Cooley MED, K Leach-Kemon MPH, Prof D T Jamison PhD, Prof C J L Murray MD); and Harvard Initiative for Global Health, Harvard University, Cambridge, MA, USA (C M Michaud MD)

Related Content:

See the figures
Download the slides (2.66MB ppt)
Map the data on IHME's GIS tool

The Lancet, Volume 373, Issue 9681 - 20 June 2009 An assessment of interactions between global health initiatives and country health systems
Health Organization Maximizing Positive Synergies Collaborative Group
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60919-3/fulltext

Editorial: Who runs global health? http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61128-4/fulltext

What can be learned from data for financing of global health?
Peter S Heller, Paul H Nitze School of Advanced International Studies, The Johns Hopkins University, Washington
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61132-6/fulltext

Address at the high-level dialogue on maximizing positive synergies between health systems and global health initiativesVenice, Italy 22 June 2009 Why the world needs global health initiatives. Dr Margaret Chan, Director-General of the World Health Organization
http://www.who.int/dg/speeches/2009/global_health_initiatives_20090622/en/index.html

Malpractice Reform to Reduce Healthcare Costs

2009-06-18T11:20:00.000-04:00

Michelle Mello and Troyen Brennan have an article in this week's New England Journal of Medicine outlining ways to enact health care tort reform. The premise, they argue, is that doctors too frequently practice defensive medicine because of fears of getting sued, resulting in excessive tests that they know are unlikely to be revealing and may even lead to harm. By changing the way courts punish liable doctors, the argument goes, substantial savings will accrue. Their rough calculation is that if even 1% of costs are reduced by changing physician practice, $22 billion will be trimmed from the health budget - not a trivial amount. From my personal experience, up to 5% of what doctors do is driven by fears of litigation. I can't tell you how many head CTs for chronic headaches I've ordered even though not a single one has ever been positive, nor is there any evidence to order such a test. It's the very small chance of a negative outcome weighted against the very large payouts that patients receive that drives decision making, pushing doctors to deviate from evidence-based decision making.

The obvious choice, to cap non-economic ("pain and suffering") damage awards, would apparently be very difficult to pass with a Democrat dominated legislature. Instead, the authors propose three more palatable compromise solutions:

"Pre-emptive strike" - A.k.a disclosure-and-offer allows medical liability insurers to disclose mistakes and offer an up-front payment without taking the case to trial. This method does not prevent the patient from going to court, but preliminary data suggests that the vast majority accept the mediation and do not pursue the lengthy and costly court proceeding. Whether this approach actually reduces costs is still being researched.
"Neutral panel" - One of the major drivers of high payouts is when a particularly gruesome or egregious violation generates huge damages from a sympathetic group of jurors. Another option is to create a special court with neutral doctors and medically trained judges who have a better sense of what was done right and wrong without the visceral driving force that some of these trials have.
"Safe Harbor" - Doctors are often sued for following evidence-based practices but the patient had a bad outcome anyway. If a panel of neutral experts decides that the treatment was within an acceptable standard of care, the physician becomes immune from personal litigation.

Of these, I personally favor numbers two and three, and I can actually see both of them working together to reduce defensive medicine. In any case, I agree with the authors that some form of tort reform should be bundled with general health care reform as a means to reduce costs and promote value-based treatment.

Senate Passes Landmark Bill to Regulate Tobacco - NYTimes.com

2009-06-11T21:08:00.000-04:00

Great news -
Senate Passes Landmark Bill to Regulate Tobacco - NYTimes.com: However this doesn't make sense "The Congressional Budget Office had estimated that the F.D.A. legislation would reduce youth smoking by 11 percent and adult smoking by 2 percent over the next decade beyond the declines that had already resulted from public education, higher taxes and smoke-free indoor space laws." How can a 11 percent reduction in children only result in a 2 percent decline in adults? Lag time doesn't seem to make sense. Great new regardless.

The AMA does not speak for all doctors.

2009-06-11T13:33:00.000-04:00

A.M.A. Opposes Government-Sponsored Health Plan - NYTimes.com

This is infuriating. As the NYT correctly points out (unfortunately near the end of the article) - the AMA does not represent all physicians. Actually, there are 250k members, and last I checked I think there were approximately 730k physicians. Most physicians have more of an affinity to either their professional medical society (e.g. internal medicine is with American College of Physicians) or with their regional society (Massachusetts docs with Mass Med Society). The AMA does have the most members, but is by no means the voice of the majority of physicians.

Some thoughts from Bill on HC Reform

2009-06-11T13:25:00.000-04:00

Bill Clinton Sees Hope for Health Care Changes, This Time - NYTimes.com

"To achieve universal coverage, instead of Mr. Clinton’s plan to require employers to provide it, Mr. Obama envisions creating a government-run health plan that would compete with private insurers.

Mr. Clinton said that as he looked at the matter in 1993 he believed that he had two options for providing universal coverage: either a tax increase or an employer mandate. Since he had already expended a lot of political capital on a deficit-reduction plan that included tax increases as well as spending cuts, he said he had to rely on the employer mandate.

“If you had an employer mandate, then you could leave the small businesses out or come up with enough revenues to subsidize the smaller employers — and since we couldn’t raise taxes, having an employer mandate guaranteed that the National Federation of Independent Businesses would join with the insurance companies,” he said. “Now they don’t have to have an employer mandate, because they can offer buy-ins. I hope they won’t give up on this public option.”

From the ATS's The Washington Letter

2009-06-06T02:31:00.000-04:00

Senate HELP Committee Releases Health Reform Overview

This week, the Senate Health, Education, Labor and Pensions Committee (HELP), chaired by Sen. Kennedy (D-MA), released a policy summary of the committee's health reform proposal.

http://finance.senate.gov/sitepages/leg/LEG%202009/042809%20Health%20Care%20Description%20of%20Policy%20Option.pdf

The summary outlines the main priorities for the committee's legislation, which is expected to be formally introduced in the Senate within the next week or so. Among the main priorities outlined are providing:

Quality, affordable health coverage for all Americans
Higher quality, more efficient delivery system
New framework for enhancing prevention and wellness
New structure of long-term supports and services for the disabled and seniors with chronic illness
New mechanisms to prevent fraud and abuse
Shared responsibility for healthcare reform

The plan outlines a number of proposals, all of which would lead to eventual universal coverage. The plan's goals include creating a public insurance option, as well as a federal Health Insurance Exchange that would provide quality and affordable options for consumers and assist those who wish to purchase private insurance. Under this plan, states would be permitted to set up their own insurance exchanges in collaboration with the federal government. Finally, the insurance industry would be governed by stricter regulation that would prohibit insurance plans from basing policies on an applicant's medical history or health status or denying coverage due to a pre-existing condition.

The HELP Committee's plan seeks to improve quality and efficiency in the healthcare delivery system through a number of mechanisms, including the development of standardized health information technology systems that are designed to conduct comparative effectiveness research, prevent medical errors, promote chronic disease management and strengthen the health workforce.

The plan would also create a Patient Safety and Clinical Delivery Institute within the Agency for Healthcare Research and Quality to coordinate best practices for health research and dissemination. The HELP Committee plans to address health workforce shortages through a new federal Workforce Commission, expanded primary care and nurse development programs and the creation of a new grant program to train professionals in geriatric care.

The new framework for prevention and public health proposes to improve chronic disease management in a number of ways, first by utilizing the "medical homes" model to provide patient-centered comprehensive health services coordinated by a case manager and by reforming the payment system to ensure reimbursement for preventative services such as screenings and affordability of these services for patients. Finally, the plan proposes strengthening community prevention programs--including those that focus on tobacco cessation--as well as promoting an increased focus on prevention and public health in medical school and residency curriculums.

--
The Washington Letter is written by the American Thoracic Society government relations office and emailed to all ATS members living in the United States. The letter keeps clinicians, scientists, and patients abreast of legislative, judicial, and regulatory issues in pulmonary, critical care, and sleep medicine. Each week's edition is archived on the ATS Web site, www.thoracic.org. If you have any questions or one more information about becoming involved in advocacy, please contact the ATS Washington office at 202-296-9770.

Porter article in NEJM on health care reform principles

2009-06-04T11:16:00.000-04:00

There's an article by Michael Porter in NEJM early release this week. For those of you who don't know Porter, he is a Harvard Business School professor and founded The Montior Group (consulting).

NEJM -- A Strategy for Health Care Reform -- Toward a Value-Based System.

He has a few major points -

1) health insurers should compete on value instead of cost - they should be required to measure and report their subscribers' health outcomes, thus driving consumer-driven value purchasing of insurance

2) Employers should be kept an integral part of health insurance in America - they have a vested interest in keeping the health of their employees

3) Eliminate the burden on people who have no access to employer based health coverage - reduce tax deductibility of insurance purchased be individuals and through employers

4) Make individual insurance affordable through large regional (not national) high-risk pools that can spread risk

5) Provide income based subsidies to lower income people to buy insurance

6) Everyone must be required to purchase insurance

---

I am pretty much on board with most of these proposals (especially six - was one that made me more of a Clinton fan during the primaries, and I'm glad Obama is now considering it) . But number two is a bit funny - since most people switch their jobs and careers numerous times in their life, I'm not convinced employees have that much stake in improving quality of their employees. The value of any interventions they undertake are likely to be accrued by Medicare in the end. So seems to me that if the average employee is only around for two to five years, that employers have little incentive to improve their employees health care.

Now, there may be other reasons to keep employers in the health care insurance game, but I'd like to hear them, because I haven't been convinced yet.

Dr. Helene Gayle at CARE

2009-06-02T14:27:00.000-04:00

from: Darke, Shannon <sdarke@care.org>
date: Tue, Jun 2, 2009 at 4:43 PM
subject: The first three years

On behalf of Dr. Helene Gayle, I would like to share with you the some of her reflections on her first three years as CARE’s President and CEO. The strategic focus that Helene’s leadership has brought to CARE was spotlighted in an interview published in the Harvard Business Review (link below). In compelling terms, Dr. Gayle explains how she applies her skills to “make the whole greater than the sum of its parts” at CARE, which she found to be “an astonishingly complex organization” when she took the helm in April 2006.

http://hbr.harvardbusiness.org/2009/04/care-ceo-helene-gayle-on-shaking-up-a-venerable-organization/ar/1

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

2009-05-27T01:19:00.000-04:00

Gawande has a great article in New Yorker on health care costs
Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

As one of my mentors said - despite what we think, physicians are finely tuned economic machines.

The politics of health care reform

2009-05-26T07:59:00.000-04:00

Obama’s Secret Supreme Court Strategy - The Daily Beast: "By drawing fire to its Supreme Court nominee, Obama’s aides believe that health-care and environmental politics may face less-intense opposition."

Fascinating. The strategy is probably true - wonder if it will work. And if it works, is that a good thing?

I.B.M. Unveils Software to Find Trends in Vast Data Sets - NYTimes.com

2009-05-21T07:55:00.000-04:00

This is pretty exciting:
I.B.M. Unveils Software to Find Trends in Vast Data Sets - NYTimes.com

if you can harness this technology on real time processing of microbiology data in a hospital, or even in a health system, you can track and squash disease outbreaks before they even happen.

the problem with the google flu tracker is that it required people to type in their personal data and there was a lag time before google could see that there was any real pandemic. NEJM article on that here. Google flu tracker to me is an imperfect solution that doesn't mine the right data. But this IBM technology, and I know other companies are out there doing this sort of stuff - is much more interesting, and powerful as a driver for improving health care.

Of side note, there was a kind of interesting new yorker article on one of the pioneers of real time data processing by malcolm gladwell. peripherally deals with data processing, but is more about team performance.

Share your Health Care Story

2009-05-21T05:44:00.000-04:00

If you haven't already, would encourage you to take a look at the president's organising tool for health care reform:

Organizing for America | Share your Health Care Story

Designing hospital wards

2009-05-20T05:59:00.000-04:00

Article in NYTimes about hospital design:
Health Outcomes Driving New Hospital Design - NYTimes.com

I worked on a study where we had to provide input on the benefits and trade-offs of having more single beds in a unit. This article seems to suggest that all single bedded units are good. The argument is that patients have increased privacy and less hospital acquired infections. Also, private rooms do reduce need for transfers, and can increase your room utilization.
When we looked into it, there was no consensus on what percent of rooms should be private, but estimates ranged from 50 to 100%. Some arguments against 100%:
-Obviously, the more you move to 100%, the larger your estate needs to be - leading to higher costs
-Private rooms have been shown to prevent hospital acquired infections a bit more than shared rooms, but one of the biggest driver of hospital acquired infections is health care workers following standard precautions, not the sharing of rooms
-There is little data to suggest that length of stay reduces for patients in private room
-Some patients in private rooms tend to feel more socially isolated
-It is harder for nurses to survey their patients and prevent injuries

I'll be the first to admit that these are not the strongest arguments against 100% private beds - I think the argument is strongest in an ICU where there is a tremendous amount of equipment and patients are critically ill. But in a general ward, I think the argument is less strong. And there are cheaper levers than redesigning a hospital from the ground up to reduce hospital acquired infections and make patients feel happier during their stay. Not arguing against 100% single bedded units, but as in any discussion like this, it's a cost-benefit analysis.

Misallocation of global health funding

2009-05-19T12:25:00.000-04:00

PATH: Two new reports highlight stalled progress against diarrheal disease

PATH and WaterAid America released reports simultaneously demonstrating that diarrheal disease receives significantly less funding than other diseases, despite accounting for 17 percent of deaths of children under five.

There's been a lot of research on the misallocation of global health funding, but diarrheal diseases seems particularly amenable to correction (and tragic) - there's not much scientific research here - it's about implementation.

Access to Experimental Therapies

2009-05-17T12:10:00.000-04:00

The landscape for experimental drugs continues to be dictated by the Food and Drug Administration with desperate patients clamoring for the one last medicine that might turn around the course of their disease. Ostensibly, these therapies are withheld from the general public because of safety reasons, but many contend that financial and legal concerns on the part of the private sector and government limits drug availability even when there is ability to pay.

Part of the problem is the bewilderingly complex drug approval process. By many estimates, it takes 10-20 years from molecule discovery to commercial availability. Furthermore, harsh copyright and trademark laws prevent small biotechnology companies from competing with existing but often poor efficacy drugs already on the market. Finally, current legislation limits making a profit on compassionate use, which completely erases any incentive to absorb the high fixed costs to produce these therapies. Streamlining the FDA's approval process, making the process more transparent, and allowing innovative knock-on therapies to enter the market will provide needed treatments to people who need it and may make it financially palatable for small companies to continue research and development.

Hans Rosling at TED on HIV

2009-05-16T13:05:00.001-04:00

You probably have seen the 2006 talk by Hans Rosling on statistics and development - and his tool Gapminder. If you haven't, Google it. Anyways, there was a new talk posted this week on TED posted this week on HIV which is pretty good. He presents statistics most readers of this blog would know (the epidemic in Africa is hetergenous, even within a country the epidemic is variable, concurrency matters)... but I think it's great they finally got around to linking gapminder to UNAIDS statistics. I wish that was available a year ago when I was making all those charts for a consulting study for a global health foundation I was on by linking disparate data sources together.

I actually like the interview with Hans Rosling better. My favorite statistic from Hans Rosling (also a sword swallower) is that "There’s about one sword-swallower per 2 to 4 million persons in each country." Random.

From NYC to DC - Thomas Frieden

2009-05-16T07:19:00.000-04:00

Seems like working in New York is a stepping stone to Washington these days. First Margaret Hamburg and now Thomas Frieden - the New York Public Health Commissioner who will head up the CDC. He had an interesting article on taxing sugared beverages which I think Bloomberg wasn't interested in running with as a policy initiative, but did praise Frieden for developing a laboratory of innovative thinking in the New York Dept of Health. Hopefully he can do the same thing with the CDC.

Health care cost containment

2009-05-15T15:19:00.000-04:00

Last week there was a flurry of news about health care stakeholders voluntarily agreeing to cut costs by 1.5% annually. Turns out they are now accusing Obama of overstating their commitment. “There’s been a lot of misunderstanding that has caused a lot of consternation among our members,” said Richard J. Umbdenstock, the president of the American Hospital Association. “I’ve spent the better part of the last three days trying to deal with it" quotes Robert Pear in the Times article (link below)

My guess is Obama's crew knew exactly what they were doing, trying to extract a commitment thinking that these stakeholders would not want to back on it in public. But when these trade groups' members freaked, they had no choice.

http://www.nytimes.com/2009/05/15/health/policy/15health.html?ref=health

Primary care workforce shortage - is it real?

2009-05-15T06:02:00.000-04:00

Recent JAMA article by Freed and Stockman tackles this question (not sure if link will work for most) from a different angle - paediatrics primary care. The authors briefly state that

"the most recentpublished data regarding pediatric residents completing trainingin 2008 demonstrated that 40% were planning to pursue a careerin primary care, with 10% still undecided... For the specialty of pediatrics,it appears that a close to appropriate proportion of traineescontinues to enter the primary care arena... While the absolute number of children in the UnitedStates has remained relatively stable, the number of pediatricianshas increased substantially. This has resulted in anincrease in the number of primary care pediatricians, from 32to 78 per 100 000 children in the period 1975 to 2005."

It is interesting - the primary care debate has really focused around adults, but this data seems pretty compelling for increasing availability of primary care for children. What the authors dont comment on is that with expansion of coverage we will need more primary care doctors, and more strategically placed (esp in underserved areas). This is definitely an issue with SCHIP expanding children's coverage. And it's what we've seen in Massachusetts - with expansion of coverage, wait times for primary care appointments have risen. Even though we have gone to 78 per 100k children, is that enough? And are they in the right places? I don't know and this article doesn't tackle those questions.

Given that you can't just turn on and off the workforce pipeline for physicians, long term workforce planning is necessary. And this is much more difficult in a fragmented education system like the US. Interesting paper, nonetheless.

Female nurses and doctors

2009-05-15T05:51:00.001-04:00

I am not going to walk into this minefield - but just going to say it is there. Interesting article in New York Times about women bullying women at work. I know it happens in the hospital between nurses and physicians a fair amount.

The article states, "... male bullies take an egalitarian approach, mowing down men and women pretty much in equal measure. The women appear to prefer their own kind, choosing other women as targets more than 70 percent of the time." Based on the "workplace bullying institute" - a powerhouse research institution, I'm sure.

But seriously, there are workplace conflicts between female nurses and female physicians; I am not even going to venture a guess as to why this occurs, but it is there. If you have thoughts, I'm curious to hear them.

Does Preventive Care Save Money?

2009-05-14T13:29:00.000-04:00

A friend of mine asked me to comment on this question. It's a tricky one.

NEJM -- Does Preventive Care Save Money?

The interesting thing here is that "although high-technologytreatments for existing conditions can be expensive, such measuresmay, in certain circumstances, also represent an efficient useof resources." That's not to say we shouldn't make all our decisions based on economic reasoning devoid of value judgments (and I mean not "economic value" but "emotional value")... But if you were to look at this question purely from an economic value perspective, then this paper fairly definitively argues that opportunities for efficient investmentin health care programs are roughly equal for prevention andtreatment. This chart pretty much says it all to me.

Regardless, health care costs in America are too high for a sustainable economic future. There is *plenty* of room to more effectively use the right treatment and prevention to make America a healthier place, while getting more (economic) value for our health care dollar.

Does the physician or the hospital matter in delivering quality health care?

2009-05-13T17:45:00.000-04:00

This is the question I'm struggling with in my current work. Numerous studies have demonstrated better results at high-volume hospitals with cardiovascular surgery, major cancer resections, and other high-risk procedures.[1],[2] And this has sparked the debate - is it the hospital, or the physicians who work in the hospital that make the hospital what it is?

What is interesting is that centralising specialist services drives quality through both a “hospital” effect, but also a “physician” effect. Teasing this out is difficult. Physicians who see more of a particular diagnosis or perform a specific procedure tend to achieve higher quality outcomes.[3], [4], [5] Hospital-based services (e.g., intensive care, pain management, respiratory care, and nursing care) play an increasingly greater role in quality as the average length of stay lengthens.[6]

So this is how I would apply it to myself - if I have a condition that is highly technical, but requires a short length of stay (e.g. carotid endarterctomy? hope i never get one...) in a hospital, I'm more concerned about the quality of the doctor. The longer my post-op care will be, I'm probably going to let the quality of the hospital be a bigger driver in my decision.

In the end we all look for the great doctor in the great hospital, right? But without clear definitions of what quality is in the first place, it's hard to figure out where to go anyways...

[1] Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301:1364-9.

[2] Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer

surgery. JAMA. 1998;280:1747-51.

[3] Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol 2000;18:2327-40.

[4] Hannan EL, Popp AJ, Tranmer B, Feustel P, Waldman J, Shah D. Relationship between provider volume and mortality for carotid endarterectomies in New York State. Stroke 1998;29:2292-7.

[5] Hannan EL, Siu AL, Kumar D, Kilburn H Jr, Chassin MR. The decline in coronary artery bypass graft surgery mortality in New York State: the role of surgeon volume. JAMA 1995;273:209-13.

[6] Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283:1159-66.

Why cost control is hard to achieve in the US health care system

2009-05-12T09:42:00.000-04:00

NY times article on Obama's health care push over the last days:

News Analysis - Obama’s Push for Health Care Cuts Faces Daunting Odds - NYTimes.com

Welcome news that industry has voluntarily committed to health care cost control. But as this article points out - any cost control will hurt someone's bottom line - this paragraph tells almost all of the story :

"Insurers and health care providers are lobbying strenuously against cuts in their Medicare payments that would produce savings of the type they profess to want. Insurers are fighting Mr. Obama’s proposal to cut payments to their private Medicare Advantage plans by a total of $176 billion over 10 years. Doctors are pleading with Congress not to cut costs at their expense, in particular by allowing a 21 percent cut in their Medicare fees scheduled to occur in January. Pharmaceutical companies and makers of medical devices worry that new products may have to pass a cost-benefit test before being approved for coverage under Medicare."

Let's hope the current consensus building and the shared aspirations in Washington turns into a shared meaningful plan of action that truly controls health care costs.

G.E. Plans More Lower-Cost Health Products

2009-05-08T09:39:00.000-04:00

GE has announced a cool strategy to produce lower cost health products.

G.E. Plans More Lower-Cost Health Products - NYTimes.com

This is in line with what we had discussed last week with cellphone ultrasound technology.

I have to admit it has an unfortunate name - "healthymagination" - I think trying to be in line with their ecomagination campaign. The website for the campaign is here. I find the partnership with Intermountain Health Care on electronic medical records exciting for US health reform and the work on devices exciting for advancing health care in the developing world.

Would be great to see other large manufacturers to undertake these sorts of initiatives such as Toyota's neonatal incubator project with CIMIT/MIT, or Phillips HealthCare's portable EKG machine for rural healthcare. There is a market just in India and China alone, just need to make the business case.

The problem ends up being distribution channels in smaller countries or less developed regions - the "last mile" problem. There doesn't seem to be that big of a gap between essential health products and consumer packaged goods (e.g. coca cola, razors or sim cards) from internal research that I've seen, but it still is there. So even with these sorts of announcements, you can make the product, but it doesn't necessarily mean it will get to the people who need it.

Anyways, wandering between topics, but I think the GE announcement is exciting.

Ultrasound Exams by Phone

2009-05-02T16:29:00.000-04:00

Now this is "game-changing". A low cost technology that could have profound impact on health care in the developing world.

Ultrasound Exams by Phone - Gadgetwise Blog - NYTimes.com:

This professor has designed an add-on to a cell phone that could remotely send U/S images to a physician. And this quote blew me away: "“I have a design for one that in a few years could sell at Walgreens for $199 and still make money,” he said."

It only took $100k of funding to create this product. And will have a tremendous impact on health care if it can be commercialized.

Assessing the World Bank's health efforts | Promising to try harder

2009-05-02T13:05:00.000-04:00

Following up on Kedar's post :

Assessing the World Bank's health efforts | Promising to try harder | The Economist

The economist has this article published the other day on the WB's external assessment. I think it is interesting that of the 220 projects, only 13% had an objective of "reducing poverty" which is the WB's overall mission and guiding principle for its existence.

I think it is great that the World Bank put out this assessment, and didn't hold back. I don't know much about the WB's governance and how projects are approved, but perhaps an "IRB-like" internal model could be established to ensure that the objectives and metrics are standardized across projects, and are in line with the WB's mission? But then again, folks I know working with the WB find the bureaucracy already cumbersome.

----
For explanation of IRB follow this link. To see WB report see here.

Fitness - Ultimate Frisbee Takes Off

2009-05-01T21:21:00.000-04:00

Fitness - Ultimate Frisbee Takes Off - NYTimes.com

this one's for you pranay.

World Bank money for health may not be effective

2009-05-01T11:43:00.000-04:00

Report today released by an independent evaluation group suggests that World Bank investments in health since 1997 may not be as effective as investments in other portfolios. HIV investments in particular seem to have gone awry with only 25% of HIV programs in Africa making the grade compared with the 80% alleged success rate of all other World Bank dollars across other programs. Conclusion: World Bank's M&E programs are weak, the World Bank should simplify its goals (health is "complex"), reduce the number of public sector programs that it funds, and reduce its expectations. I guess it's better to have your evaluations look better than to have outcome for patients look better. The World Bank, with its now tripled health budget of $3billion, must be able to do better than this...

X-prize = Build the perfect health system

2009-04-29T12:57:00.000-04:00

Readers of Health Policy Dialog...check this out. This is a really exciting offer from the X-prize this year to design a new health care system for an American community. Would be really exciting to develop a model system (though the scope is small only 10,000 people).

http://www.xprize.org/future-x-prizes/healthcare-x-prize

WASHINGTON (Reuters) Apr 15 - Organizers of the X Prize, who have set up
contests for space travel, DNA research and super-efficient cars, said on
Tuesday they are offering $10 million to the winner of a contest to
transform the health of people in a small U.S. community.

They invited written ideas for the Healthcare X Prize, and said they would
choose five for a three-year trial run in real communities or at employers.

The winner would be chosen based on a "community health index" of measures
such as an improved ability to climb stairs, reductions in visits to
emergency rooms and health costs.

"We need to show that the innovation works and then that the innovation is
scalable. It's going to be a public solution," Angela Braly, president and
chief executive officer of WellPoint Inc, a major U.S. health insurer that
is helping sponsor the prize, told a news conference.

"We are looking for teams to help individuals and communities proactively
improve their own health and (that) of their families," added Dr. Peter
Diamandis, chairman and chief executive of the non-profit X Prize
Foundation.

"Teams are actually going to have to design and implement a system across a
community of 10,000 people that improves health by 50 percent during a
three-year trial period."

The competition and all results will be audited by an independent panel of
judges and "trusted third parties," the group said in offering the prize
plan for a 45-day public comment period.

"The Smithsonian would never have funded the Wright Brothers to invent the
airplane," said Newt Gingrich, former speaker of the U.S. House of
Representatives who now helps head up the Center for Health Transformation.
"I think this will bring diversity."

The plan gives teams 18 months to conceive, model, and submit their plans.

Healthcare reform is near the top of the agenda for President Barack Obama,
the Congress and U.S. society as a whole. More than 80 percent of Americans
have said in several surveys they believe the U.S. healthcare system needs
substantial reform.

The United States ranks last among 19 industrialized nations on health
outcomes, quality and efficiency, according to a report by the non-profit
Commonwealth Fund.

In 2008, the United States fell from 15th to last on measures of
preventable death from chronic conditions such as asthma and heart attacks,
the report found.

Medical bills cause half of all

U.S.

personal bankruptcies, most among
middle-class workers with health insurance, according to a 2005 study by
researchers at Harvard University.

Global Health Career Advice

2009-04-28T20:11:00.000-04:00

Kris Olson , in prep for our panel on GPH careers this Friday, shared this document with me:

Global Health Career

V. good set of questions to consider for people considering careers in global health. I think our group's list posted earlier today is more comprehensive in terms of where GPH jobs are. The broader questions are all worth considering... sort of the pro/con/considerations when weighing which of the options we listed before one should take...

Specter To Switch Parties - The Caucus Blog - NYTimes.com

2009-04-28T16:53:00.000-04:00

Specter To Switch Parties - The Caucus Blog - NYTimes.com

This is unbelievably huge for health care reform given the recent nuclear option Obama was talking about earlier this week to avoid a filibuster when the HC bill comes up later this spring. Granted, it strikes me he did this partially to preserve his senate seat given he was losing to his opposition in the Republican primaries... but Specter has gotten much more moderate in recent years, and there really isn't space for moderate Republicans (see prev. post on Sebelius). His support on expanding NIH funding was critical. I'm thrilled for the short term debate on health care, but for the sake of the long term, I do hope the Republican party gets its act together and can put up a sensible opposition so we can have a healthy debate of a spectrum of ideas.

Just noted that kedar talked about this on his post also

Goosby for PEPFAR

2009-04-28T15:58:00.000-04:00

This story comes buried on a day of some very serious political transformation with Arlen Specter switching party loyalty and clearing the way (possibly) to health care reform amongst other heavily democratic policy priorities:
Eric Goosby from UCSF was named yesterday to be Obama's pick for PEPFAR. Goosby's a Clinton-era veteran with good global health credentials (runs Pangaea). Will be interesting to see if he can keep up the funding line for PEPFAR which some have reported may be under threat.

Careers in global health

2009-04-28T11:15:00.000-04:00

Am on a small informal panel discussion end of this week at MGH on careers in global health. Kedar, Nupe and Celine helped me put together this initial tree of careers in global health to help me prepare. If you have any thoughts, please let us know on how we can improve this. Thanks -

· Academia

o university based NIH research

o center based (e.g. HIGH) or divisions of Global Health at Hospitals (Penn, Pitt, BWH, MGH, UCSF, WashU, Columbia, etc) a la Salman Keshavjee, Jim Kim

o Maintain an academic faculty position as a hospitalist or consultant essentially at 75% time and spend the rest of time abroad with another institution further down the tree

· Industry

o pharma (e.g. novartis vaccines)

o consulting (e.g. mck, broadreach)

o occupational health (e.g. mining companies, agriculture, environmental health)

· NGO/ Non profit

o country specific (e.g. PHI - haiti/Rwanda, Aurum Institute for Health Research)

o theme based (e.g. MSF, IHI - pt safety / quality)

· Foundations (Gates, Rockefeller, Clinton, KFF, Elizabeth Glaser, Doris Duke, UN Foundations)

o portfolio manager (e.g. circ funding evaluator for gates)

· US Gov't

o Development based entities (e.g. USAID)

o foreign policy based entities (e.g. state dept)

· Multilaterals

o WHO, UNICEF, UNFPA

o WB - looking for docs to help them evaluate country loan proposals and make sure funding is in line with objectives

· Advocacy

o in-country: Treatment Action Campaign, AIDS Law Project, ARASA

o US-based: Treatment Action Group

· Bioethics

· Regulatory/Intellectual property

· Think tanks e.g Council on Foreign Relations

Allocation of US Global Public health funding

2009-04-27T18:08:00.000-04:00

Kedar, thanks for linking to the KFF report.

What is interesting is that there is essentially a 50-50 split between the two engines of US GPH funding disbursement - the state department which is interested in GPH as a foreign policy tool, and the "development-oriented" entities like USAID. I wonder if this mix has changed over time (I imagine more has shifted into state dept over time) and what has driven this shift (rise of Anti - american terrorism and understanding that destabilized countries from famine, poverty, health inequity could be addressed through gph funding).

Also most money goes through bilateral channels. Wonder if this will change in Obama's new vision of multilateral global cooperation and what impact that will have on reprioritization of GPH issues.

Sebelius nomination and the RNC

2009-04-27T17:58:00.000-04:00

I haven't been following the Sebelius nomination too closely, as I assumed that it would be with minimal issues. Michael Steele's comments (RNC Chairman who has been more scared of Rush Limbaugh than the American public) that Sebelius should be blocked unless she discloses more about her position on late-term abortions is ridiculous.
First off - the problems of the American health care system has nothing to do with the abortion debate
Secondly - isn't abortion now just a legal issue that will be decided in the Supreme Court? I'm sure there's probably some minor, arcane stuff that HHS could do, but in the end this is a legal issue.

So frustrating. Can't imagine that michael steele will be around much longer.

----
24 April 2009
The Boston Globe

The head of the GOP called on President Obama yesterday to withdraw Kathleen Sebelius's nomination as health secretary unless she answers more questions on abortion, after Republicans blocked immediate action on Sebelius's confirmation in the Senate, probably pushing a final vote to next week at the earliest.

Michael Steele, Republican National Committee chairman, said Sebelius, the Democratic governor of Kansas who would complete Obama's Cabinet if confirmed, has not been forthcoming about her ties to a Kansas abortion doctor, George Tiller.

"Significant questions remain about Governor Kathleen Sebelius's evolving relationship with a late-term abortion doctor as well as about her position on the practice of late-term abortions," Steele said in a statement. "If Governor Sebelius and the Obama administration are unwilling to answer these questions, President Obama should withdraw her nomination."

The White House declined to comment. A spokesman for the Senate majority leader, Harry Reid dismissed Steele's complaints.

"This is nothing more than a baseless attack from someone desperate to stake a claim as the leader of the leaderless Republicans and get right with the right-wing of his party," said Jim Manley, spokesman for Reid.

The Senate Finance Committee approved Sebelius this week with 2 of 10 GOP votes. Several Republicans - including the top committee Republican, Chuck Grassley of Iowa - raised concerns about her initial failure to tell senators how much campaign money she got from Tiller.

When the discrepancy became public, Sebelius acknowledged getting an additional $23,000 from Tiller and his abortion clinic beyond the $12,450 she initially reported. She apologized and said it was an inadvertent error.

Sebelius told the Finance Committee that she personally opposes abortion, but she also has a long record in Kansas politics of supporting abortion rights. She has drawn the ire of antiabortion groups for repeatedly vetoing legislation sought by antiabortion groups to impose more regulations on abortion clinics and rewrite the state's restrictions on late-term abortions, including yesterday blocking a bill to require doctors to provide more information to the state.

USG investments in Global Public Health

2009-04-27T13:59:00.000-04:00

Ever wondered exactly how the USG invests its dollars in global health...Here's the breakdown from KaiserFF and Stimson Foundation. Very enlightening and interesting reading for anyone working in the field.

High Level Commission on Global Public Health

2009-04-27T13:55:00.000-04:00

The newly formed "Commission on Smart Global Health Policy" will advise the Obama administration, among others, on how the US should spend its substantial resources on global health. This Commission will issue its report in December 2009 and will likely have a big impact on funding priorities for the largest overall financial contributor to global health budgets in the world. William Fallon and Helene Gayle to co-chair the Commission.
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=58139

2009-04-24T13:13:00.000-04:00

The Economist
Health care in India: Lessons from a frugal innovator
http://www.economist.com/displayStory.cfm?story_id=13496367

NEJM -- Health Care and the New Administration

2009-04-24T05:16:00.000-04:00

Just came across this link - very easy to navigate compilation of US Health Care Reform articles published in the Journal -

NEJM -- Topics -- Health Care and the New Administration

Changes in the Incidence and Duration of Periods without Insurance

2009-04-23T11:48:00.000-04:00

Fascinating article which I'll need to dig deeper into. In short - David Cutler (Harvard health economist, advised Obama during campaign) has written an article in NEJM -- Changes in the Incidence and Duration of Periods without Insurance.

Key points in discussion are:
-Incidence of uninsured periods is rising over time

-When people become uninsured they are uninsured for shorter periods

-Uninsured periods are shorter because more people are obtaining public insurance

-From 2001-2004, persons in fair or poor health were substantially more likely to lose and to gain insurance as a result of the increase in public insurance

My thoughts:

-Time periods of comparison of 83-86 to 01-04. Uninsured periods were shorter likely due to expansion of economy which led to 1) greater employee health benefit access and 2) expansion of public health programs as tax base increases (and efforts to expand coverage for children)

-Incidence of uninsured periods rising maybe due to decreasing time with employer, leading to increasing periods of unemployment

- Rise of public insurance may crowd out private insurance

- The recession is going to have a profound impact on these trends. States can no longer continue to fund at the rates they have been - there will be likely reduction in public health benefits and programs. Unemployment is at some of the highest levels we have seen in recent history.

- This all makes me question the sustainability of current employer based health care:
*when patients are sick, they are more likely to lose their job
*the disabled account for I think approximately 10% of the uninsured but account for 50% of health care costs of the uninsured
*those who are employed are increasingly finding themselves "underinsured" - due to expansion of public health insurance and rising costs which limit the coverage that employees can provide

Thoughts that definitely need to be fleshed out and definitely need more of a fact base. Curious to hear your thoughts.

Linking Health Care to Economic Opportunity

2009-04-20T18:43:00.000-04:00

Today I attended the 2009 Annual Hope Street Group Colloquium. The HSG is a bipartisan think tank focused on developing and implementing policies that promote economic opportunity - currently around the issues of education, health care reform, asset building, job creation and home ownership.

My role specifically is as a participant of the bipartisan working group on health care reform and adviser to the Economic Opportunity Index.

Economic Opportunity Index (EOI) | Hope Street Group

The EOI is a tool that policy makers, media and citizens can rely on to assess the potential impact of policies (such as health care reform) will have on economic opportunity for all Americans. The Index measures individual economic opportunity, as defined by "expected lifetime real income":
-Expected - luck, circumstance, and scoietal change always play a role in economic outcomes
-Lifetime - a single year might give a misleading snapshot of one's overall circumstances
Real - adjusted for inflation
-Income - economic, rather than non-economic opportunities such as freedom of expression

The EOI is an interesting tool that I think can really help policy makers quanitfy and measure economic opportunity change from policy reform. One of many challenges the Obama administration will have as the conversation heats up around health care reform is to explain to the public WHY health care reform is needed. I'm starting to come to the opinion that any health care reform in America will limit access (for those who already have access) in order to drive real meaningful cost control. If you limit access, you need to explain why they - and the entire system - will be better off. I have more thoughts on that, which I will post in the next few days.

Anyways, back to the EOI. The EOI looks at health care by determining what factors lead to better health - which implies more capacity for work and more productive working years. Some examples of factors are diabetes prevalence, worker absenteeism, violent crime rate, etc. So concretely, what if we increase access to health care from x% t o y%? How would that change what white women could earn?

As I listened to the conversations today, two things struck me. First, the need to sell health reform to the public - and I think the EOI can help push this. Secondly, if we decide to continue with employer based health care, then employers need more tools to understand how their employees' health can lead to more productivity. Large corporations - the Microsofts and GEs of the world - already get this, and are concerned about health care costs. However, the smaller companies need easier tools to allow them to quantify impact of improving health care on their worker productivity - because in addition to offering it as alternative compensation, employers provide health care to keep their employees productive.

Anyways, my role developing the health care portion of the EOI is just starting, but take a look, let me know what you think of the tool, and if there is anything you think is missing or can change. This is interesting for me since I have always looked at health care in isolation - how do you drive quality, contain costs and increase access - but this is the first time that I'm pushing myself to connect health care to larger macro and microeconomic phenomenon.

Over the course of the week I'll continue to post thoughts from the colloquium itself.

How far away are we from personalized medicine?

2009-04-16T13:52:00.001-04:00

This week's NEJM has a number of articles on genomewide association studies and genetic risk prediction.

NEJM -- Genomewide Association Studies and Human Disease

Courtesy of a company called Proventys, I came across this curve below, which I found helpful in thinking about what personalized medicine could really mean, and what are the levers available for delivering it. Of disclosure, Jeff and I know the Chief Medical Officer - Surya Singh - who is also a hospitalist at the Brigham.

As you see from this chart, genetic studies can help determine both baseline and preclinical risk. However, I think we can continue to do more in developing out clinical risk models - that tiny little last bullet under dynamic testing. As we digitize more medical records, and migrate to increasingly standardized medical vocabulary, I can imagine a not so distant future where with powerful computing and robust clinical risk modeling, a physician can better understand and act upon a patient's "preclinical progression" or predisposition profile. This week's NEJM articles suggest unfortunately, that we may be further from understanding baseline risk than we originally thought, but that doesn't mean that personalized medicine is dead in the water as the New York Times suggests.

The NIH Stimulus Package

2009-04-14T16:51:00.000-04:00

NEJM -- The NIH Stimulus -- The Recovery Act and Biomedical Research

The US health care system, despite its many issues, is the undisputed leader in health care research and innovation: more than two-thirds of all Nobel laureates in medicine over the past decade worked in the United States, and more than 80 percent of venture capital in the global health care sector flowed to the United States in 2007 (McK quarterly, Dec 2008).

The NIH is, in my opinion, is the primary driver of innovation in the health care system. The charts in the article are powerful - essentially a flat curve in the budget from 2003 to 2009, when you adjust for inflation.

I was in DC for the past two days, and had an interesting conversation with a Robert Wood Johnson Scholar, who said she's seen research where the average age of R01 awardees is rising, suggesting that people aren't getting their K awards funded as quickly as they used to (the entry level grants) and the old-timers keep accruing grants and aren't giving up to allow the younger folks to enter the research "market".

I know this bill has kept a few of my friends interested in pursuing research careers - they feel that the government is finally interested again in promoting meaningful biomedical scientific research. Hopefully we can sustain NIH's growth, and continue to keep bright, young talent within academia.

Docs who facilitate torture should lose their license

2009-04-09T08:40:00.000-04:00

Pardon this entry if it is preaching to the converted. I hope most people have seen or read about the Red Cross report that outlines the role that American health care providers, including physicians, played in torturing detainees in Iraq and Cuba. (http://www.nytimes.com/2009/04/07/world/07detain.html?scp=1&sq=red%20cross&st=cse) Doctors, psychologists, and PAs monitored torture episodes, including waterboarding, prolonged standing (of amputees), and confinement of people in small boxes. Some of their actions, such as monitoring pulse oximetry during waterboarding, directly facilitated torture.

Some may argue that these doctors' activities protected torture victims. However, I believe this line of reasoning dumbs-down the essence of medicine and ignores the true role of a doctor: to serve as an advocate for patients. Patients are people at their most vulnerable moments: they are sick for reasons they often do not understand. They may not be able to think clearly. They are cared for in hospitals and clinics foriegn to them, and trapped in health care systems that, around the world, are at best confusing and at worst harmful. And they are scared, even if they are not being tortured.

The role of a doctor is to serve as a champion for patients, and to ensure they thrive amid the chaos of illness. Making sure they do not die during torture does not meet this bar. Health care providers need to stop torture before it happens. If they cannot do this, they need to speak up and publicize what is happening. Unfortunately for the medical professionals involved in torture, speaking up or taking other actions to help their patients may have cost them their jobs or landed them in legal trouble with the military. While this is certainly an unenviable situation, I do not think these costs outweigh their duty as physicians and other medical providers to care for their patients.

Implications of pushing the limits of when to start HAART for HIV infection

2009-04-08T08:50:00.000-04:00

NA-ACCORD data is out - an observational cohort study that attempted to shed more light on the age-old question that has plagued the field - when do you start HAART. Below is the link to the NEJM commentary by Sax and Baden:

NEJM -- When to Start Antiretroviral Therapy -- Ready When You Are?

The commentary is thoughtfully written, but seems to sidestep the major question in my mind - assuming we shift recommendations to early HAART initiation - what is the implication for implementing these recommendations in the developing world, where a majority of new and existing infections reside? Already countries are cash strapped to expand public health expenditures, and I understand the GFATM is concerned about it's coffers given the global recession. This study has clearly pushed for the clinical effectiveness - now comes the tricky costing exercise to see what's "cost-effective."

I know that there are actual RCTs out there - HPTN 052 / ACTG 5175 I think was supposed to answer a similar question on when to start - curious to hear what folks think.

Drug trials in the developing world

2009-04-06T16:25:00.000-04:00

Pfizer to pay �50m after deaths of Nigerian children in drug trial experiment - Africa, World - The Independent

I have to sadly admit I didn't realise the Constant Gardner was based on a true story.

I once took a look at global clinical trials, and a majority of big pharma clinical trials done in the developing world is for infectious diseases, cardiovascular disease or oncology (this is all public access information from clinicaltrials.gov). Many of them use contract research organisations to conduct their clinical trials. This industry is very sophisticated now (the outsourcing of clinical trials) so hopefully this sort of blatant disrespect of human life and the scientific process won't happen again, but unfortunately, I suspect it will without proper oversight (formal or informal).

Rehospitalization as a cost driver - is it important?

2009-04-02T10:25:00.000-04:00

Article yesterday in NY Times highlights a NEJM paper that found that almost 20% of Medicare patients are rehospitalized within a month of discharge.

Many Medicare Patients Rehospitalized, Study Finds - NYTimes.com

The paper estimates that rehospitalization costs the system $17 billion and then there's a quote from Dr. Anne-Marie J. Audet of the Commonwealth Fund stating "“Given the current financial situation, this is no longer something we can ignore.”

I'm convinced there's an argument around QUALITY of care, but not convinced that it is a pressing issue for COST CONTAINMENT.

Let's have some fun with maths. Assuming a formal health economy of $2 trillion, readmissions only account for 0.85% of US health care spend. Now let's say I'm being unfair - let's limit to only US inpatient spend of $458 billion in 2006 - that's still only 3.7% of spend. Then one can argue this is a Medicare patient population - and that given their age, one is to expect that a portion of these patients are in their last years of life and will of course need multiple readmissions. So the real question is what is the cost to the system of unnecessary readmissions. Granted, maybe that's what this study did - I need to dig a bit deeper. Regardless the numbers don't work for me to be convinced that there is a pressing cost issue here.

Amy Boutwell, a colleauge of ours and a med school classmate, is quoted by the NY Times in this piece - she now works at the Institute for Healthcare Improvement - let's see if we can get her to comment on the importance of readmissions. Keep a note for comments and hopefully we can get her to post her thoughts!