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

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

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

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

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

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

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

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

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

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

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?

  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 recent published data regarding pediatric residents completing training in 2008 demonstrated that 40% were planning to pursue a career in primary care, with 10% still undecided... For the specialty of pediatrics, it appears that a close to appropriate proportion of trainees continues to enter the primary care arena... While the absolute number of children in the United States has remained relatively stable, the number of pediatricians has increased substantially. This has resulted in an increase in the number of primary care pediatricians, from 32 to 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

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?

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-technology treatments for existing conditions can be expensive, such measures may, in certain circumstances, also represent an efficient use of 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 investment in health care programs are roughly equal for prevention and treatment. 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?

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...

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[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

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

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

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

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.

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

Fitness - Ultimate Frisbee Takes Off

Fitness - Ultimate Frisbee Takes Off - NYTimes.com

this one's for you pranay.

World Bank money for health may not be effective

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...