Lab Soft News

UnitedHealth to Develop Telehealth Network with Cisco

Bruce Friedman — 2009-07-17T08:39:34-04:00

UnitedHealth has exhibited certain tendencies in a past to trample on the rights of physicians and patients (see, for example: UnitedHealth Settles Suit with New York Attorney General Cuomo; UnitedHealth Draws Criticism for Its Out-of-Network Reimbursement Policies; UnitedHealth Receives Warning Letter for Posting Doctor List) and also been involved in an options scandal involving its CEO (UnitedHealth CEO to leave amid options probe). Now comes the news that it will build, in collaboration with Cisco, a telehealth network (see: UnitedHealth, Cisco to Build Telehealth Network). Below is an excerpt from the story:

UnitedHealth Group Inc. and Cisco Systems Inc. announced a partnership to build a network linking patients and physicians across the country via video and medical-information technology, establishing a foothold in a telehealth market that is expected to grow to more than $6 billion by 2012. UnitedHealth, the country's second-largest health insurer, said it is investing tens of millions of dollars in building the open network with Cisco's video-conferencing, broadband and other medical-networking capabilities. The network will incorporate an array of technologies from other companies as well, such as fiber-optic cameras for looking into ears and digital medical records, creating a virtual doctor visit....Ultimately, UnitedHealth and Cisco say they plan to connect thousands of physicians and hospitals with patients in rural and underserved areas, simulating in-person physician visits from terminals in homes, malls, workplace sites and other outlets. The insurer said it hopes to add the telehealth network to the vast arsenal of health-care services it already sells, such as medical-claims processing systems and consulting services to hospitals. It also plans to integrate the telehealth services into health plans that it administers for employers, state Medicaid programs and other customers....One major challenge so far has been that Medicare and most private insurers don't reimburse for remote health-care services. But that is expected to change as health plans come under more pressure to reduce costs and improve the quality of care.

For more than at least a decade, I have been reading rosy predictions about the future of telemedicine and telehealth. Permit me, please, to view this new announcement by UnitedHealth and Cisco with a certain measure of skepticism. Note the obligatory reference in the article to the need to provide services to "patients in rural and underserved areas." This doesn't quite seem to mesh with the next sentence in the same article the references the company's vast arsenal of health-care services that it already sells to hospitals and others. I believe that UnitedHealth will always place emphasis on the bottom line and it's a little hard to understand how the company intends to wring revenue out of rural and underserved populations. However and more to the point, I am really not that concerned about whether UnitedHealth and Cisco have a telemedicine business model that will be successful. What concerns me more is the thought of UnitedHealth exercising a high degree of control over the clinical data transmitted over a network. In my opinion, this is worrisome, given some of the company's past issues.

Repurposing Outpatient Clinics and Medical Procedure Units as Integrated Diagnostic Centers

Bruce Friedman — 2009-07-16T06:57:52-04:00

I have been an advocate of the merger of pathology and radiology into what could be described as the new medical specialty of diagnostic medicine. This merged specialty can also referred to as integrated diagnostics. The integration of pathology and radiology is related to the idea of the development of Integrated Diagnostic Centers (IDCs). These are clinics staffed by multidisciplinary teams and focused on the goal of diagnosing disease faster, better, and less expensively than the norm today. Most such centers today specialize n the diagnosis of breast masses. In the U.K, they are referred to as one-stop breast cancer clinics (see: The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.).

What is the basis for the claim that IDCs can arrive at diagnoses faster, better, and less expensively? The faster and higher quality assumptions are derived from the multidisciplinary nature of these centers. Professional hand-offs, communication, and procedure scheduling is easier and more efficient when health professionals are working side-by-side. The less expensive assumption relates to the fact that diagnoses can be arrived at faster and with fewer administrative costs. As experience accumulates in such centers, the workflow can only improve. In time, computerized algorithms can be developed for these centers that automate workflow. Dr. Jonathan Braun, Chairman of the Department of Pathology at UCLA, has created a Radiology-Pathology Center in Los Angeles in collaboration with the Department of Radiology. He discussed the project in a lecture presented at the 2009 Molecular Summit (see: UCLA Radiology Pathology Center (Or, Slouching Towards Bethlehem: Gestation of a Multimodality Diagnostics Initiative).

Many existing clinics with examining rooms, pathology, and radiology services could be adapted, in part or totally, to IDCs. Similarly, existing colonoscopy centers could also be modified to include the services of pathologists and radiologists and to provide one-stop diagnostic services. In this way, biopsies of suspicious polyps, for example, could be quickly processed and diagnosed while the patient is on-site. In other words, there is no reason that the "one-stop" concept should be confined to patients with breast masses. Small hospitals that are no longer economically viable currently might also be suitable for conversion to IDCs.

CDC Releases On-Line Environmental Health Tracking System

Bruce Friedman — 2009-07-15T07:25:32-04:00

The future of tethered personal health record (PHR) products, as in the case of HealthVault and Google Health, lies on the web. The term tethered here means that these electronic records have links to hospital and physician office EMRs such that data from them can be copied to the PHRs. Moreover, web-based PHRs also provide the opportunity to link to other valuable medical information resources on the web. For example, a consumer might highlight the name of a drug or disease in his or her personal health record and launch a search of trusted web resources to learn more about the topic. A recent article (see: CDC Launches Online Health Tracking Network) alerted me to another possibility -- tracking environmental exposures and chronic health conditions on the web. Below is an excerpt from the article:

The Environmental Health Tracking Network [of the CDC] is the first program available to the general public, as well as scientists and health professionals, that follows environmental exposures and chronic health conditions on the CDC's website....The online tool presents information about air and water pollutants and environmental health issues such as asthma, cancer, and heart disease in a single resource. By unifying the health demographic information in a single program, the CDC say it hopes to help scientists make a variety of environmental and health connections that heretofore couldn't be analyzed in one location....To further increase public awareness of the new tool, the CDC released a video advertisement for the Health Network on YouTube, stressing the correlations between environmental and personal health as well as the information now available through the CDC's website. Although 17 local and state health departments currently contribute to the online resource, the CDC hopes to expand the network to all 50 states and develop a complete national picture of public and environmental health....CDC officials said the resource has already had 73 success stories, in which information from the Web site has led to action to control potential illnesses from environmental exposure. The agency cited a Utah case in which a concerned citizen contacted the Utah Department of Health about what he thought was an unusual number of cancer cases in his neighborhood. Prior to the availability of the new software, a multi-year study would have been necessary to collect data. But through the Utah Tracking Program, officials were able to respond in less than a day, telling the man his local cancer rate was no higher than in the rest of the state, CDC officials said.

Bravo! What a great idea and effort on the part of the CDC scientists and public health officials. The home page of the Environmental Health Tracking Network features the following three categories: Environments, Health Effects, and Location. Under Health Effects are the following four categories: Asthma, Cancer, Childhood lead poisoning, and More health conditions. Clicking through Cancer and then Leukemia under Additional Links displays a page captioned Leukemia and the Environment. The site, even in this early stage, provides valuable data. The site is a little quirky and probably designed by an epidemiologist. Once you get the hang of it, you will find a treasure trove of useful health data.

A mash-up is a Web application that combines data or functionality from two or more sources into a single integrated application (see: Web-Based PHR Mash-Ups). The availability of the Environmental Health Tracking Network provides an early view of the potential for mash-ups linking our PHRs with other health resources on the web. For example and in this particular instance, the owner of a PHR could be automatically alerted to local environmental problems such as an outbreak of an infectious disease. Contrariwise, the CDC could use the national network of PHRs for reporting local outbreaks of conditions like flu or food-borne bacterial diseases. This would be similar to the syndromic surveillance systems being installed in hospital emergency departments and used in connection with bioterrorism monitoring.

Calculating Reimbursement for CTs and MRIs: The Utilization Assumption

Bruce Friedman — 2009-07-14T08:01:39-04:00

There are various ways in which the U.S. government has chosen to reduce Medicare payments to medical imaging centers. One of them is that reimbursement for medical imaging services is based, in part, on an equipment utilization assumption (see: ACR: Reducing medical imaging costs requires a short term investment). Below is an excerpt from this article, a guest post on KevinMD written by Dr. James Thrall representing the American College of Radiology (ACR):

The Administration recently recommended a radical change to the Medicare reimbursement formula for imaging services. Specifically, it called for increasing the formula’s utilization assumption to 95 percent — even more extreme than Medicare Payment Advisory Commission’s suggested increase to 90 percent. The utilization assumption is the percentage of a facility’s operating time that the equipment is assumed to be in use and is a key component of the Medicare formula used to calculate reimbursement. If the assumption is dramatically higher than the actual time a facility’s machines are in use, the center will be significantly underpaid for their services. According to data recently collected by the Radiology Business Management Association, imaging centers in rural areas operate equipment approximately 48 percent of the time their offices are open. Imaging centers in non-rural areas operate equipment approximately 56 percent of office hours. A 90-95 percent utilization rate for CT and MRI scans would result in an additional 30+ percent reimbursement cut for these modalities, on top of an average 23 percent hit resulting from imaging provisions in the Deficit Reduction Act of 2005 and even more reductions called for in the CMS’ proposed Physician Fee Schedule Rule. With cuts this deep, there will be minimal if any access to advanced imaging in rural America. Even suburban and urban providers may find it hard to continue to offer the same level of service — all leading to longer travel for care and longer wait times.

Although I think that this note was designed to engender support for the plight of the owners of imaging centers, particularly in rural areas, it seems to have had an opposite effect on me. First of all, I was struck by the relatively small difference between the utilization rate of rural centers compared to the non-rural ones -- only 8%. Secondly, I was also impressed by the fact that the overall average utilization rate in the U.S. for CT and MRI scans was only about 50%. These data suggest to me that too many of these expensive imaging devices have been deployed in the country. This is not a novel insight. It was probably the basis for the adoption of the utilization assumption in the first place.

One of the basic planks of healthcare reform is that U.S. consumers are not going to get all of the services that they feel they deserve or need in the future. As the reimbursement system reduces the compensation for CT and MRI images, the business model for some of the current imaging centers, perhaps disproportionately in rural areas, will no longer be viable. Some of these centers may go out of business. The remaining imaging centers will probably try to modify their patient work-flow and extend their operating hours in order to stay afloat and serve a larger number of patients. In rural areas, this may result in longer trips for some patients. Because of their reduced population density, rural areas cannot be served by the broad range and ready availability of services that are offered in more populated areas. This applies to retail shopping malls as much as it does to healthcare delivery. This idea will not appeal to politicians from the less populated states.

Self-Management of Heart Disease: A New Approach to Participatory Medicine

Bruce Friedman — 2009-07-13T07:24:42-04:00

The idea of persuading or empowering consumers to take more responsibility for their own health is broadly taking root (see: "Participatory Medicine" and Its Relationship to Clinical Lab Testing). The well-established previous name for this movement is Health 2.0, which emphasizes the role of the web in providing broad access to information about health and disease. A recent article on the web discussed the role of patients in helping to manage their own heart disease (see: Tackling Heart Disease Together or Alone: The Behavioural Science of Self-Management). Below is an excerpt from it with boldface emphasis mine:

Heart disease is the leading killer in the U.S. and throughout most of Europe. People’s behaviour can protect and reduce risk of heart disease, and interventions to help people “self-manage” exist. But what is the best way to “self-manage”? ... One thorough definition is that it relates to activities undertaken by the person who has a “chronic” or “long-term” condition such as asthma, multiple sclerosis or arthritis. These activities include problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning and self tailoring. Interventions or programmes are designed around these activities to help support people to manage their own illness. The idea is that following attendance at a programme of some sort, the activities and skills learned will be continued to be used, thus improving health, maintaining fitness and/or quality of life and reducing the risk of future acute episodes of ill health....Researchers at the University of Michigan explored the effect of the format of a self-management intervention for women with heart disease by comparing a “self-directed” programme to a “group” programme to a control group....The results revealed a remarkable difference. Eighteen months after the intervention, data were collected. For the “self-directed” intervention, cardiac symptoms such as chest pain and dizziness were reduced in number, frequency and impact. For the “group” intervention, weight loss and exercise capacity (in terms of how far a person can walk within a set time) were improved. This is despite the fact that the information and instructions provided in both programmes were the same.... Our health and its care is now a collaborative endeavour in which we are involved actively and with responsibility. Self-management is increasingly included in health policies.

The formation and success of groups and programs for weight-loss are well-documented (see, for example: Statewide Weight-Loss Competitions Achieve Record of Success). Moreover, there are a number of web sites designed to assist diabetics in the self-management of their disease such as Diabetes Self-Management. It seems to me that it would be relatively easy to design web sites specializing in self-help for patients with chronic heart disease. However, I must admit that I had never encountered such sites and a quick search of the web did not turn up any of them. This is probably understandable given that the category of heart disease is very broad and also that liability issues could arise if consumers turned to self-help programs instead of seeking local physician care. Nevertheless, I could envision health systems developing chronic heart programs as extensions of their own local acute and chronic care programs on the web to facilitate greater patient engagement in self-care. I would be interested in feedback from readers of this blog about whether programs such as these do exist with some details.

Providing Patients Easy Access to Physician Notes in Their EMRs

Bruce Friedman — 2009-07-10T07:12:58-04:00

I have been intrigued over past years by discussions concerning patients' rights to view their own medical records. An argument is frequently made by physicians that much of content in a hospital or office EMR is unintelligible, confusing, or unsuitable for patients to view. This may be true. However, many hospitals, on request, will allow patients to view their own medical records while in the hospital. Additionally, patients post-discharge can also request a copy of their chart, generally to provide to other physicians. A recent article takes up this same topic in the context of a project at Beth Israel Deaconess Medical Center allowing patients access to their physician notes in the EMR (see: Patients to get a look at physicians' notes). Below is an excerpt from it with boldface emphasis mine:

One doctor wrote that a patient was acting paranoid. Another typed that she had ordered tests to make sure a patient didn’t have cancer. Such notes, written in a patient’s medical records after an appointment, can be candid and blunt - at times more so than doctors are to patients face-to-face. Amid the national push to computerize medical records and make them more open to patients, one of the most intense areas of debate is whether patients should be allowed to see their doctors’ notes online....But the notes usually aren’t readily available to patients because hospitals and doctors’ groups fear that they will misunderstand medical jargon, take offense at a blunt observation, or worry unnecessarily about a precautionary test. Beth Israel Deaconess Medical Center, however, is about to begin a project called “open notes’’ in which about 100 doctors at the hospital and two other sites will allow 25,000 to 35,000 patients to read their physicians’ notes for a year as part of their online medical record. Researchers hope to learn whether the notes prove more useful than objectionable. They hypothesize that access to doctors’ notes will improve care partly because patients will become more knowledgeable about their treatment and about their doctors’ instructions....[Developers of the project] are developing detailed surveys to give patients, including whether they read the notes and found them useful, and whether they discovered errors.....The ultimate measure of success will be whether doctors and patients want to keep sharing notes at the end of the study....In Boston, Partners HealthCare, which includes Massachusetts General and Brigham and Women’s hospitals, is discussing making “summary notes’’ available to patients but not the full note....Partners is experimenting with providing patients with lab results online as soon as they are available and before the doctor has a chance to review them. The results “so far suggest that the sky does not fall in,’’....

The Open Notes Project will enable all patients enrolled in the study to view the physician notes entered into their medical record. I think that this is a very good idea. It's a good idea because it will cause physicians to be more careful about what they enter into the medical record, avoiding hearsay and off-the-cuff comments. Access to physician notes also provides the opportunity for patients to more actively engage in their own care processes. In fact, I suspect that ad lib narrative notes may have largely outlived their usefulness, to be replaced mainly by structured notes selected from pull-down menus available within the EMR. Such documentation may not be as colorful as some of the narrative comments of past years but will provide overall clearer documentation about the status of a patient. I am obviously very enthusiastic about the Partners HealthCare plan to provide on-line access to patients of their own lab test results (see: Physician Failure to Inform Patients of Abnormal Lab Tests All Too Common).

Physician Failure to Inform Patients of Abnormal Lab Tests All Too Common

Bruce Friedman — 2009-07-09T07:36:14-04:00

I am quite familiar with the burden that is placed on patients regarding follow-up on lab studies. I finally have my personal physician trained, after many years of trying, to send me an email with my test results as well as his interpretation. It therefore came as no surprise when a recent article revealed that patients are frequently not informed about their test results, abnormal and otherwise (see: Physicians Frequently Fail to Inform Patients About Abnormal Test Results). Below is an excerpt from the article with boldface emphasis mine:

New research shows that physicians failed to report clinically significant abnormal test results to patients -- or to document that they had informed them -- in one out of every 14 cases of abnormal results. In some medical groups, the failure rate is close to zero; in others it is as high as one in four abnormal results. The analysis of 5,434 patient records from 23 physician practices across the country was led by Dr. Lawrence P. Casalino...and published today in the Archives of Internal Medicine. Dr. Casalino and his co-investigators revealed that groups using simple processes to manage test results had lower failures rates. Groups that did not consistently use these processes had both higher failure rates and physicians who were dissatisfied with their group's processes for managing test results. The study also found that having an electronic medical record did not reduce failure-to-inform rates -- and even increased them -- if the practice did not have good processes in place for managing test results....The study suggests that five simple, common-sense processes are useful for dealing with test results:

All test results are routed to the responsible physician
The physician signs off on all results
The practice informs patients of all results, normal and abnormal, at least in general terms
The practice documents that the patient has been informed
Patients are told to call after a certain time interval if they have not been notified

[I]n many cases, physicians and their staff told patients that 'no news is good news' -- meaning they should assume that their tests are normal unless they are contacted. This is a dangerous assumption.

I really don't have much to add to this item -- the results and conclusions are quite clear. Physician practices need simple procedures for ensuring that patients are informed about all test results. There needs to be documentation embedded in office procedures that this patient communication step has been completed. As a double-check, patients should assume that their physician office procedures may be faulty and should take it as their personal responsibility to be aware of all lab test results. As noted above, an office EMR does not increase the chance that test results will be communicated to patients. Although this article is silent on the topic of personal health records, providing patient access to test results via a PHR could help to correct this communication problem. However, patient-accessible PHRs are not offered by most practices and this situation will probably not change much in the near future.

Bioethicists Discuss Risks of Sharing Genetic Information on the Web

Bruce Friedman — 2009-07-08T08:28:07-04:00

Consumer genomics offered on the web is a burgeoning enterprise. Genomic testing web sites fall roughly into two categories: those with a medical/scientific orientation such as DNADirect. Sites such as these use a vocabulary such as genomic medicine to indicate an interest in the diagnosis of genetic diseases in the population being tested and provide professional genetic counseling. Other web sites such as 23andMe provide disease discovery by genetic testing but use a vocabulary including words like ancestry, sharing, and community to indicate that one of their missions is to provide networking with other individuals who may be blood relatives. These latter sites have a social/networking orientation. It goes without saying that the business model of these latter sites raises some privacy issues (see: Risks of sharing personal genetic information online need more study, Stanford bioethicists say). Below is an excerpt from this article with boldface emphasis mine:

With just $399 and a bit of saliva in a cup, consumers can learn about their genetic risk for diseases from breast cancer to diabetes. Now, thanks to social networking sites set up by personal genomics companies, they can also share that information with family, friends and even strangers on the Internet....But according to bioethicists from the Stanford University School of Medicine, sharing genetic information online raises a host of ethical questions....Because genetic information applies to more than one person, issues of privacy and consent become complicated. "For example," [a bioethicist commented], "if you receive information on your breast cancer risk and share it with others, you might also be sharing information about your daughter's risk for breast cancer — even though she never consented to have that information shared."....In most cases, customers mail in a DNA sample for sequencing, and then get both raw data and an interpretation of their genetic profile. A few companies, including 23andMe, also let customers create a public profile and share their genetic data through a company-sponsored social networking site. For now, there aren't any laws that govern the exchange of genetic information online. But as genetic analysis becomes cheaper and more widespread, more and more people will have access to their DNA code — and experts fear that consumers may share genetic data without realizing the potential implications for themselves and their families. In addition, both consumers and their health providers may have trouble interpreting data provided by personal genetics companies....Estimates of disease risk are often based on small, unreplicated studies in the biomedical literature, but consumers may not understand how preliminary this data is. "Results depend on the number and type of markers that are used, as well as how robust their databases are," [the bioethicist] said.

As I understand the issues raised in this article plus prior knowledge, there are at least three problems raised by genomic testing web sites: (1) although the tested individual may provide informed consent for the test, the results may have a harmful effect on other blood-related individuals who have not provided such consent; (2) sharing personal genetic data with strangers may lead to mischief at some later time based on the knowledge that the tested individual is predisposed to develop a disease; and (3) estimates of disease risk may be based on faulty or inadequate data, which is to say that they may not be correct and the life of the recipient of the incorrect data may be colored or even ruined. Hospital clinical labs and reference labs are highly regulated by state and federal bodies due to the criticality of the test results being reported by them. It seem quite odd that there is no similar regulatory oversight for consumer genomics web sites. I suspect that the issue is not whether this regulation will occur but rather when it will take place.

The Transition from Pre-Diabetes to Diabetes Comes into Better Focus

Bruce Friedman — 2009-07-07T08:09:22-04:00

More sophisticated use of medical diagnostics will enable the identification of diseases in earlier and earlier stages. For example, there are various types of pre-clinical manifestations of diabetes. One of them that is now well-recognized is the metabolic syndrome. A state of apparent wellness can co-exist with a predisposition to disease which can transition to a pre-disease and then to clinically overt disease (see: Predisposition to Disease and Pre-Disease on the Health Continuum). Pre-disease is frequently recognized by abnormal lab test results. A recent article provides some additional clues about the transition from pre-diabetes to diabetes (see: The trajectory of pre-diabetes comes into focus). Below is an excerpt from it with boldface emphasis mine:

[T]the Lancet [recently] published a study of 6,538 British civil servants who were followed for over 13 years....Five hundred and five of these subjects eventually developed diabetes (7.7% of the study population). Interestingly, when the measures of blood glucose and insulin resistance were examined for the people who developed diabetes and for the people who did not, they behaved quite differently. The people who did not develop diabetes during that 13 year period did not experience any increase in fasting blood glucose levels but they did experience a slow increase in their non-fasting glucose levels. Meanwhile, the people who did develop diabetes had higher values both for fasting blood glucose as well as the non-fasting glucose level....What this study shows is that the onset of type 2 diabetes can be divided into 2 stages. There is a long period of reasonably successful compensation where blood sugar levels are slowly rising but things are pretty much under control. During this period the pancreas is compensating for the metabolic problem by increasing insulin production. Then the patient enters into an unstable metabolic state which lasts from 3 – 5 years before diabetes onset. During this time, insulin secretion can no longer handle the metabolic deficit and blood glucose levels rise rapidly. The importance of this observation is that most people with pre-diabetes are identified after they have entered this unstable period of rapid deterioration. It is likely that if lifestyle changes were initiated during the more stable portion of the process, the results would have been vastly more successful....We need a study that looks at the costs of early identification and lifestyle modification in these people who are likely to develop type 2 diabetes a decade hence. Since the rate of increase in blood glucose levels was vastly different for people who develop diabetes from those who do not, it should not require a decade to figure out the answer.

On the basis of clinical studies such as this one, we are now beginning to better understand the transition from pre-diabetes to clinically overt disease. We are also getting clues about when intervention such as lifestyle changes can alter or prevent the onset of frank disease. This value of such studies is so obvious, one wonders why a number of them have not been performed prior to this time. I suspect the reason is that most medical researchers have had little interest in the past in studying pre-disease such as pre-diabetes. This may have been because there were few good therapeutic options available for pre-diabetes (see: Few Good Treatment Options for Pre-Diabetes and Metabolic Syndrome) or lifestyle interventions were not as well understood. At nay rate, my hope is that studies such as this one will peak the interest of younger physicians who will then begin to delve deeper into predictive/preventive medicine.

The Challenge of Diagnosing Predisease in Our Healthcare Delivery System

Bruce Friedman — 2009-07-06T09:23:49-04:00

New technology is inexorably driving medical diagnostics toward more frequent discovery of predisease. Medical diagnostics here should be taken to encompass both the clinical laboratories and medical imaging. Below is an article describing one further example of how a new nanotechnology technique is "thousands of times more sensitive than conventional methods to low levels of proteins or nucleic acids that show a person could develop a certain disease (see: Inventor to Receive MIT Prize). Below is an excerpt from it:

The Massachusetts Institute of Technology expects to name Chad Mirkin, creator of a range of sensitive diagnostic tests for diseases, as the winner of the $500,000 Lemelson-MIT Prize, a premier award recognizing invention....Mr. Mirkin's products use nanotechnology, which is based on the science of very small particles, to help researchers study diseases. His disease-detecting method, branded as Verigene, is thousands of times more sensitive than conventional methods to low levels of proteins or nucleic acids that show a person could develop a certain disease. The method can return results in an hour as compared with several days, in some cases....The scanning technique -- called dip-pen nanolithography -- creates patterns on several materials on an extremely small scale. Scientists can then use the patterns to learn more about the nature of certain cells and distinguish between normal and cancerous cells.

Our healthcare delivery system is ill-prepared for an influx of large numbers of patients with predisease (see: Predisposition to Disease and Pre-Disease on the Health Continuum; Wellness, Preventive Medicine, and the Classic Disease Model; Genomic Testing, Pre-Symptomatic Disease, and Health Insurance). Put another way, our capacity to diagnose disease is becoming less aligned with our ability to treat disease and reimburse physicians and hospitals for these treatments. Another unintended consequence of this fundamental shift in medical diagnostics is that many of our diagnosticians may be required to make therapeutic recommendations for which they may be unprepared. For now, perhaps the only solution is watchful waiting until we have a better understanding of this trend of increasing numbers of patients carrying predisease diagnoses.

Do Physicians and Hospitals Want to Make Us Healthier?

Bruce Friedman — 2009-07-03T07:45:09-04:00

A very fundamental issue was raised in a recent note in the HIStalk blog based on a comment from a reader. The topic under discussion is why hospitals and physicians are resisting the conversion to hospital EMRs. The theory being raised is that hospital executives avoid EMRs because they make hospital business operations more transparent and subject to outside scrutiny. Thrown into this conversation is also the idea that treating the sick is more lucrative than assisting the well. Below is the comment and response:

From HIPAAHound: “Re: interesting take on the resistance to electronic medical records [A Pound of Cure: The federal government is about to spend big on health-care IT. Too bad the medical industry has a vested interest in inefficiency]. I have to say I agree with much of this reasoning, most especially where HC costs are increased by for-profit insurance companies looking to avoid paying claims by constantly moving the target for approved claims, thus sending admin costs for providers sky high, and the avoidance of any mechanism which might expose any of these practices to the general public. I am amazed that these practices have not been exposed already in our debate over HC reform.”

Mr. HIStalk response: Bet on it: whoever has the most lobbyists wins. This Technology Review (MIT) article is hardly complimentary: it says healthcare could have already gone digital if it wanted to, but resists to keep its lucrative business model out of the public eye. It also hints an another truism: it takes a lot of sick people to keep the big bucks flowing, so there’s not much incentive to lose customers by making them healthier.

Here's a provocative quote from the A.Pound of Cure article by Andy Kessler linked to in the comment above:

An even bigger threat to the sickness industry's business model is that by allowing automated tracking of patients over time, electronic health records would set the stage for early detection and preventive medicine. Currently, the entire industry is organized around treating sickness, rather than keeping people healthy in the first place. Three-quarters of health-care spending is devoted to chronic care, but the National Cancer Institute and the Centers for Disease Control and Prevention allot just 12 percent of their budgets to research on early detection. Moreover, the payment system is structured around reimbursement for treatment rather than prevention.

I generally concur that physicians and hospitals are most oriented to, and comfortable with, the treatment of disease and not the promotion of wellness. This is largely the result of physician training and the fact that our healthcare reimbursement system does not provide compensation for predictive and preventive medicine or wellness. I do not subscribe to the idea that hospital execs avoid computerization to "keep [their] business model out of the public eye." The business side of hospitals has been highly automated for decades. It is primarily the clinical side of hospital operations that has been resistant to automation and EMR deployment. This is largely the result of factors such as the inadequate outdated computer systems available in the market. resistance on the part of physicians to the shifting clerical duties to them, and failure on the part of physicians to embrace a standardized nomenclature for describing clinical observations and events.

Want a Job at the Cleveland Clinic?: Smokers Need Not Apply

Bruce Friedman — 2009-07-02T08:19:58-04:00

I am generally supportive of anti-smoking legislation and rules. However, I have a feeling that we may be approaching a point where the rights of smokers are being seriously trampled. After all, smokers at work are already relegated to practicing their vice outdoors so second-hand smoke ceases to be a problem for the non-addicted. The Cleveland Clinic has now taken the step of refusing to even hire smokers. The details of this plan are presented in what appears to be a personal message posted on the web from Dr. Delos Cosgrove, Chief Executive Officer and President of the Cleveland Clinic (see: A Message About Smoking). Below is an excerpt from it with boldface emphasis mine:

While we are on the topic of smoking, I understand that there are differences of opinion about our recently announced policy to stop hiring smokers as of September 1st. Many people have told me that they totally agree with the idea. I have also seen and heard comments that what we are doing is discriminatory....Some have questioned the wisdom of our new hiring policy....But we are not the first organization to implement such a policy.The World Health Organization, American Cancer Society and more than 6,000 companies across the country have adopted similar policies in an effort to promote a healthy workplace. It's a growing trend; one that will likely keep gaining momentum....Some also have claimed that our new policy is not really about health, but about saving money....First, with our new policy, any applicant who fails the nicotine screening will be referred to a free tobacco cessation program that we pay for. Those who are successful in quitting will be encouraged to reapply after 90 days....We also are committed to taking a lead role in shifting the national focus from "sick" care to "health" care. As a true "health care" provider, we must create a culture of wellness that permeates the entire institution, from the care we provide, to our physical environment, to the food we offer, and yes, even to our employees.....Secondly, no one can deny the staggering cost smoking places on society. The U.S. Centers for Disease Control and Prevention estimates that smoking costs more than $75 billion annually in direct and indirect medical costs, and that businesses lose approximately $3,400 each year for every employee who uses tobacco because of increases in health costs and decreases in productivity related to smoking breaks....While current employees will not be tested, I encourage any employee who smokes to please consider enrolling in a tobacco-cessation class.

I suspect that the Cleveland Clinic would not have pursued a hiring policy that bars smokers unless they were convinced that it would withstand a legal challenge. Note that he cites other organizations that have employed a similar policy. I further suspect that legal issues may have been the reason that they decided not to fire existing employees who smoke. To do so would have made the new policy retroactive, which may have been grounds for legal action.

For me, the most interesting point in the rationale for barring smokers as employees is the following statement: We also are committed to taking a lead role in shifting the national focus from "sick" care to "health" care. I strongly believe in this concept and have published a number of previous notes about wellness versus the classic disease model (see: Wellness, Preventive Medicine, and the Classic Disease Model, Moving LISs Toward Greater Support for Preventive and Predictive Medicine, The Relationship Between Predictive and Preventive Medicine, How Predictive/Preventive Medicine Will Change Healthcare Delivery and the IT That Drives It). It's refreshing to see a large health system taking positive steps in this direction.

The PHR as a Tool to Enable Consumers to Take Responsibility for Their Own Health

Bruce Friedman — 2009-07-01T07:18:14-04:00

Healthcare consumers need to take more responsibility for their own health, particularly to avoid or ameliorate chronic diseases such as obesity, diabetes, and heart disease. They also need access to the proper tools to achieve this goal. Tethered personal health records (PHRs) enable the transfer of critical health data from hospital and office EMRs to consumer-controlled records. With the exception of some health systems like Kaiser Permanente and the Cleveland Clinic, most providers have not been quick to endorse tethered PHRs. John Moore, who blog over at Chilmark Research, suggests that Microsoft is pursuing an international strategy for its PHR, HealthVault (see: HealthVault’s International Strategy). This will presumably enable consumers to self-manage, to some degree, their chronic diseases and, in so doing, help to mitigate the rising cost of healthcare. Below is an excerpt from his note:

The key driver for all countries is not much different than what we are experiencing in the US. All are looking to reduce their medical risk profile by providing citizens and physicians better tools to manage health. Primary objectives include:

Support telemedicine with device connectivity (HealthVault Connection Center).
Provide mechanisms/systems/tools, via HealthVault, to allow citizens to better self-manage and where possible minimize chronic diseases.
Proactively engage citizens in their health by providing them with access to their personal health information leading to better, healthier and more knowledgeable decisions and subsequently, behaviors.

...Finland currently has 90% of its physicians using an EMR, but like most countries Finland continues to see healthcare costs rise. Therefore, Finland is now looking at HealthVault as a critical component to take their national healthcare system to another level with deeper, direct engagement of their citizens and thereby mitigate cost increases. (In theory this makes sense, but there is no conclusive evidence that indeed this will work. Today, most are going on faith.)

It's interesting that Finland enjoys a 90% acceptance rate among physicians for EMRs but continues to experience rising healthcare costs. My personal belief is that office and hospital EMRs, if well designed, will allow physicians to work smarter and more efficiently but will usually not reduce the cost of healthcare. The reason for this is the very high capital cost of computer purchase and maintenance, including high-priced computer support personnel. In addition, EMRs and LISs provide the opportunity to generate new hospital management reports and perform functions relating to patient safety, quality, and surveillance that were not previously available with manual systems.

As John points out, there is still no firm evidence that patient self-help (see: "Participatory Medicine" and Its Relationship to Clinical Lab Testing), enabled by PHRs, can reduce costs. Nevertheless, I believe that it's worth a try. The challenge with tethered PHR will be convincing/forcing hospitals and physician offices to replicate patient data to patient PHRs. Most office and hospital EMRs are not designed to perform this function. In addition, much of the clinical data in these systems is not organized or phrased in such a way that it can be understood by healthcare consumers. Finally, much of the effort and capital costs to achieve this end on the part of physicians and hospitals would not be compensated under current payment systems.

"Participatory Medicine" and Its Relationship to Clinical Lab Testing

Bruce Friedman — 2009-06-30T07:13:42-04:00

We should encourage healthcare consumers to actively participate in their own healthcare. The web will be a very important factor in this process by providing access by consumers to sophisticated healthcare information. Web-based personal heath records (PHRs) constitute another key element in consumer self-care by providing them ready access to their electronic health records. Web sites that enable consumers to order lab tests for themselves (the so-called direct access testing or DAT sites) are another facet of this approach to healthcare. One can use Health 2.0 (see: Introduction to Health 2.0) to refer to consumer-directed healthcare but Kevin Kelly make reference to what may be a better term -- participatory medicine. Below is an excerpt from his web site describing his involvement in this area (see: Journal of Participatory Medicine):

I've long been interested in medical self-care. The idea of patients taking responsibility of their own health and healing seems to me to be essential in the long run. [My web site] Quantified Self was started in part to collect a certain kind of tool that... might give you data which could be used to maintain or improve your health. Data measurement is only one way to improve your health, and it should certainly not be the only way. The main thing is that health is your job, and doctors and hospitals are your assistants and advisors, but to live this way requires a lot of education, skills, and support. I'm not the only person to head in this direction and for the past three decades a large number of dedicated doctors, public health agents, self-care journalists, and patient activists have been working on all kinds of ways to increase the role of informed patients. The newest channel in this effort is the launch of a peer-reviewed science journal dedicated to research in the field of "participatory medicine" -- as in patient participant. (Sometimes labeled Health 2.0)

There is a important link between direct access testing (DAT) and PHRs. Some of the web sites offering DAT services provide access to a free on-line PHR. This service originated back to the days when tethered PHRs such as HealthVault had not yet been offered. I think that tethered PHRs will ultimately triumph over the untethered ones because they will contain both "official" health records generated in physician offices and hospitals as well as data entered into the record by the consumer himself or at his direction. DAT lab test results would fall into this latter category. Direct access lab testing enables the consumer to compare self-ordered test results with those generated in an office or hospital setting. In this way, the consumer can monitor the status of his health or chronic diseases at more frequent intervals than may be available during office or hospital visits. Such self-monitoring by lab testing goes to the heart of participatory medicine.

The Inclusion of Molecular Diagnostic Testing in Comparative Effectiveness Studies

Bruce Friedman — 2009-06-29T08:17:50-04:00

I have made the point in previous notes that clinical lab testing, particularly molecular diagnostics, will comprise a key component of most comparative effectiveness research (CER). See, for example, the following: Comparative Effectiveness, Healthcare Cost Reduction, and Virtual Decision Trees; A Look at Deloitte's Healthcare Reform Pyramid: A Strategy for Reducing Costs; Moving Resources from the Therapeutic to the Diagnostic Silo; Biomarkers Used to Assess Treatment Efficacy. I suspect that most lab professionals assume that this same conclusion will be reached quickly by most comparative effectiveness researchers. Nevertheless, I was encouraged that the Association for Molecular Pathology (AMP) took advantage of the surge in CER funds to submit a letter to the Federal Coordinating Council for Comparative Effectiveness Research to make this very point (see: AMP urges inclusion of molecular diagnostic tests in comparative effectiveness research). Below is an excerpt from the article describing this letter:

The AMP letter recommends the development of a model process for CER regarding clinical laboratory tests. This model should include the creation of a panel of experts consisting of physicians and scientists, including laboratorians with molecular diagnostics expertise, economists, and reimbursement specialists; the creation of an electronic clearinghouse for information on CER projects similar to clinicaltrials.gov; the development and adoption of standards for the collection and storage of data from genetic testing laboratories in order to facilitate interoperability among databases; and a requirement that data from technologies and tests being assessed be generated from CLIA-, CAP-, ISO-, or FDA- certified institutions. Additionally, AMP wrote that in order to routinely incorporate information that relates patient outcomes to genetic variations into clinical care, there is a need to jointly fund large, carefully designed comparative effectiveness trials for molecular tests with observational comparative effectiveness studies that complement the randomized controlled trials by including patients who do not necessarily meet the inclusion criteria for traditional prospective trials.

For the sake of efficiency, let me distill from this article the key recommendations made by AMP retarding all comparative effectiveness research (CER) going forward:

Development of a model process for CER regarding clinical laboratory tests
Creation of an electronic clearinghouse for information on CER projects
Development and adoption of standards for the collection and storage of data from genetic testing laboratories
Requirement that data for studies be generated by CLIA-, CAP-, ISO-, or FDA- certified labs
Need to fund comparative effectiveness trials with observational comparative effectiveness studies that complement the randomized controlled trials

I personally find all of these recommendation eminently reasonable. I believe that there are a number of parallels between evidence-based medicine (EBM) and comparative effectiveness research (CER). I have been critical about EBM research in the past (see, for example, Flaws in Evidence-Based Medicine). Part of my criticism of EBM studies, and perhaps of CER of the future, is that they have taken too long to perform and established an overly rigid a set of conditions such that their results have not been generally applicable in clinical practice and thus frequently ignored. The recommendations of AMP about future CER such as the use of a model process, the establishment of an electronic clearing house on the web, and the need for observational studies can help to ameliorate some of these problems.

The Link Between Healthcare Reform and Post-Graduate Medical Training

Bruce Friedman — 2009-06-26T07:00:35-04:00

Politicians and pundits have been stressing over the years the need for more primary care physicians. It's clear that this group of professionals fills a very important niche in our healthcare system, providing office care and coordinating referrals to medical specialists when necessary. By the way, such coordination is critical for the well-being of patients and inadequately, or not at all, compensated. It's time to launch a serious dialogue about the link between healthcare reform and post-graduate medical eduction with particular emphasis on the training of primary care physicians. A recent article is a good place to start (see: What Medical Education Has to Do With Health Reform). Below is an excerpt from the article with boldface emphasis mine:

Medicare spends $9 billion a year paying for the medical residencies where doctors get their clinical training. That training needs to change as part of the nation’s big health-reform push, argued a report...from MedPAC [Medical Payment Advisory Commission], the commission that advises Congress on Medicare. The report looked broadly at health-system reform, touching on a number of issues we’ve been hearing a lot about lately — the way Medicare pays doctors for volume rather than quality, for example, and how private insurers in the Medicare Advantage program are paid more than traditional Medicare programs. But we haven’t heard so much about how medical education fits in....Specifically, the report cited “the relative lack of formal training and experience in multidisciplinary teamwork, cost awareness in clinical decision making, comprehensive health information technology, and patient care in ambulatory settings.” More generally, the report noted, medical residencies are largely based in hospitals. That gives doctors great training in treating acutely ill, hospitalized patients, but doesn’t do so much to teach them to treat patients in outpatient clinic, where primary care docs do much of their work — and where key targets for reform, such as better management of chronically ill patients, will occur. MedPAC said it will look at ways to shift the funding for medical residencies to more closely link doctor training to long-term health-reform goals.

At the present time, most residents are trained in academic medical centers or in community hospitals that have a relationship with an academic medical center. The sickest and most complicated patients gravitate to, directly or by referral, hospitals such as these. This patient flow occurs with good reason because these facilities frequently tend to offer the best care. Medical residents at academic medical centers can opt for training that emphasizes outpatient care rather than critical care. However, I suspect that the experience of most may be lacking in particular areas such as those emphasized in the article quoted above: multidisciplinary teamwork, cost awareness in clinical decision making, and the requirements of running a small business such as an office practice. I am not sure that our teaching hospitals can provide the physician training that is required for a reform agenda. It's a topic that badly needs additional discussion.

The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.

Bruce Friedman — 2009-06-25T06:59:27-04:00

Important topics for the future of healthcare will be integrated diagnostics, the merger of pathology and radiology, and integrated diagnostic centers (IDCs). The latter are multidisciplinary, integrated clinics where patients can be referred for rapid and efficient diagnosis. It turns out that IDCs are called "one-stop" breast clinics in the UK and that they have achieved an admirable record of success there (see: Missed cancer diagnoses rare at ‘one-stop’ breast clinics). Below is an excerpt from an article about these facilities with boldface emphasis mine:

Missed breast cancer diagnoses are very rare among UK women discharged from one-stop symptomatic breast clinics, indicate reassuring findings published in the British Journal of Cancer. Patients with breast concerns may attend clinics with multidisciplinary teams (MDTs) offering “triple assessment” of clinical breast examination, mammography and/or ultrasound imaging, and where necessary, needle biopsy....To determine how often women attending these clinics are later diagnosed with breast cancer, the team reviewed data from 7004 patients who were discharged after initial assessment between 2001 and 2003. Over 36 months of follow-up, 29 patients were subsequently diagnosed with breast cancer, giving a symptomatic interval cancer rate of 0.9, 2.6, and 4.1 cases for the first, second, and third years, respectively. The researchers note that breast cancer diagnoses were most common in women aged 40–49 years who “present the greatest imaging and diagnostic challenge.” Multidisciplinary review indicated that, of the women with a subsequent breast cancer, 10 women experienced no delay in diagnosis, and seven experienced probable delay....This gave triple assessment by a MDT an overall diagnostic accuracy of 99.6% and a missed cancer rate of 1.7 cases per 1000 women discharged.

I enthusiastically support the notion of multidisciplinary diagnostic centers (one-stop breast clinics in the U.K.) staffed by multidisciplinary teams (MDTs). Such an approach seems particularly apt for what is described above as a "triple assessment" of breast masses. In a previous note, I had this to say about MDTs from the perspective of cancer diagnosis (Bootstrapping the Integration of Pathology and Radiology):

[T]he most successful current examples of such [integrated diagnostic] "centers" where heterogeneous groups of medical specialists collaborate are cancer hospitals. The unifying factor for such centers is that all of the various physicians working in them can focus on patients with a specific type of disease -- cancer. In a diagnostic center, all of the various specialists will collaborate on a set of processes in the healthcare delivery continuum: the diagnosis of disease, the assessment of disease prognosis based on the diagnosis, and the choice of therapy based on the nature of the diseased tissue or neoplasm.

Of great interest to me that the overall diagnostic accuracy for women aged 40-49 with a breast mass in U.K. one-stop centers was 99.6%. I find this diagnostic accuracy rate quite remarkable. This group of patients is described as "presenting the greatest imaging and diagnostic challenge" for breast cancer, presumably because of the high incidence of concomitant benign breast lesions in them. Such a high accuracy makes sense to me in the setting described using all available diagnostic techniques. All of these factors provide an opportunity for effective team management and seamless hand-offs in a short time span.

Microsoft's Amalga/HealthVault Strategy Becomes Obvious

Bruce Friedman — 2009-06-24T07:14:41-04:00

John Moore, who blogs over at Chilmark Research, always presents EMR and PHR issues with great clarity and knowledge. He recently attended the Microsoft Connected Health Conference and posted a blog note about some of the impressions that he gained there (see: The Borg Lives in Healthcare). Below is an excerpt from his note concerning the strategy that he believes Microsoft in pursuing with regard to Amalga and HealthVault, with boldface emphasis mine:

To some extent, that is the impression I walk away with from my attendance at the Microsoft Connected Health Conference. That indeed, Microsoft and its Health Solutions Group (HSG) has indeed been assimilated by the healthcare sector. Now this is not necessarily a bad thing for Microsoft or the broader market but it does signal some important changes within the organization and more broadly confirms the strategy implied in recent announcements. Primary among them is Microsoft HSG’s migration from an early consumer-centric strategy to an enterprise strategy. Yes, HSG will continue to stand behind the consumer’s right to their health data and the consumer’s right to share that data with whom the consumer deems appropriate... [N]o longer is Microsoft interested in drawing the consumer to HealthVault... [R]ather, Microsoft will go to market directly targeting large enterprises, currently providers, ideally selling them a combination package of Amalga UIS [Unified Intelligence System] and HealthVault as in the case of the recent New York Presbyterian announcement.

John is right on all counts but I can't say that any of this comes as a surprise to me. On September 30, 2008, I presented my view of the emerging Microsoft strategy (see: Some Clues About the Microsoft Healthcare IT Strategy). Here is an excerpt from that note:

Microsoft's healthcare strategy is more obvious to me at this time than that of Google and consists of at least the following...elements:

Develop a hospital EMR with Amalga starting with selected alpha sites as noted ...above. The company will thus be able to determine whether their product is competitive in the U.S. market.
Sign high-profile deals with major health systems...to offer the HealthVault PHR to patients served by these health systems.

I would like to take some credit for my predictions of nine months ago but I won't -- it was just too obvious. Microsoft's was faced with two options after it purchased the Amalga EMR: (1) sell hundreds of millions of dollars of EMR software to hospital executives with HealthVault as a dangling appendage; or (2) distribute HealthVault to consumers free of charge and with no reliable business model to generate revenue for the company. It was clear to me that Microsoft would be much more comfortable and accustomed, from a corporate culture perspective, to participating in power lunches with hospital executives than working with the more demanding and vocal healthcare consumers. For their part, hospital executive are also most comfortable with bulky, over-engineered software that takes months of training to use properly and may never work as expected. Any after all, this is the type of product that Microsoft surely knows how to deliver. No need to cite product names here.

Earning an MD Degree in Six Years to Reduce the Debt-Load of Medical Students

Bruce Friedman — 2009-06-23T08:15:42-04:00

I was admitted to medical school without an undergraduate degree nearly 50 years ago. I had completed the obligatory courses for admission and the University of Michigan Medical School accepted me. Medical schools and professional medical associations are now under pressure to reduce the number of years required to obtain an M.D. because of the increasing debt-load of newly graduating physicians (see: AMA Looks to Put Brakes on Debt Load of Med Students). Below is an excerpt from this article with boldface emphasis mine:

Medical students who went into debt could figure on owing $126,714 in 2007 on average, up from $88,331 in 2000, according to the Association of American Medical Colleges. You can figure the debt tab has only gone up since then. Such statistics are being cited by American Medical Association as docs prepare for their [upcoming] confab in Chicago next week....Suggestions under consideration would take approval by powers greater than the AMA. They include providing tax deductibility for tuition and loans, and expanding state and federal scholarship opportunities. But another cost-cutting approach is investigating ways to reduce the length of medical schooling—perhaps through competency-based curriculums, or through combined B.A./M.D. programs. Some schools already offer a variety of such combination programs, though only a handful actually shorten the total length of training. For those that normally don’t worry about the school loans carried by docs, remember that the med school debt load can have broader implications. It’s one of the most common reasons given for problems like the shortage of physicians and the skewing of medical professionals toward specialty practices.

How about consideration of programs to reduce the number of years required to obtain an M.D.? I personally believe that developing a combined B.A./M.D. degree programs is the wrong approach. This was attempted in the past at the University of Michigan Medical School -- the six-year program was called Inteflex and was ultimately abandoned (see: Be flexible -- Eliminating Inteflex would limit students' options). One of the reasons for its demise was that the 18-year-olds admitted to the program were being guaranteed admission to medical school after completion of their undergraduate courses. For many and because the pressure for admission to medical school was eliminated, they decided to take it easy, often receiving their degrees in eight or more years. Many also decided belatedly that the medical career path was not suitable for them.

Here's my modest proposal for shortening the number of years to earn an M.D. without spending a dime and without burdening medical school deans and curriculum committees with additional work. In order to understand this proposal, you need to understand that for most medical schools, the fourth year studies are comprised mainly, or even totally, of electives rather than mandatory courses.

Medical schools should begin to accept students, as in former years, after three years if they have fulfilled all of their undergraduate course requirements. If this is impossible given the number of such prerequisites, this number should be reduced such that it is possible for most applicants to quality for the new program.
On a selective basis, medical school should allow some students to skip their fourth year and graduate in three. This should only be an option for the most mature students who have amply demonstrated their ability to function well as they pursue their post-graduate medical training.

The likelihood of such a plan being adopted is probably slim. It will require minimal planning and, after all, medical school deans are compensated for their curricular planning expertise. The deans and presidents of undergraduate institutions would also probably oppose such a plan as they did when I pursued it many years ago. They will argue that physicians need the broader liberal arts background. However, I am not convinced that one more year of undergraduate studies will achieve this goal.

Cost-Cutting as the Key Element in Healthcare Reform

Bruce Friedman — 2009-06-22T08:16:35-04:00

Important to all of us is the high cost of healthcare. Recently, a note about the over-utilization of health services with special focus on a case study of McAllen, Texas (Much of Escalating Cost of Healthcare Due to Physician-Driven Overutilization) has drawn national attention. Dr. Abraham Verghese has published a timely and well-reasoned op-ed piece in the Wall Street Journal (see: The Myth of Prevention) in which he concludes that cost-cutting must be the key element in any major federal healthcare reform. The title of the piece alludes to the face that behavioral preventive medical initiatives (e.g., weight loss, smoking cessation) are relatively inexpensive and can result in reduced healthcare expenditures. Contrariwise, screening preventive health measures can be very expensive (think CT scans for broad disease screening programs) and only a minority of consumers may have serious diseases detected. Below is one excerpt from the article addressing why there will be widespread opposition to cutting healthcare costs:

... I just don’t see how the president can pull off the reform he has in mind without cost cutting....[A] dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since....It means that all of us—doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others—are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub....But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal.

Here's another quote that contains the "how" regarding to healthcare cost-cutting:

Contrary to what we might think, comparative studies show us that the US when compared to other advanced countries, does not have a sicker population....The bottom line is that our health care is costly because it is costly, not because we deliver more care, better care or special care. Alas, a solution that does not address the cost of care, and negotiate new prices for the services offered will not work; a solution that does not put caps on spending and that instead projects cost-savings here and there also won’t cut it. Leaders have to make tough and unpopular decisions, and if he is to be the first President to successfully accomplish reform there does not seem to be much choice: cut costs.

So here's the essence of what I have personally carried away from the Verghese article supplemented by my own understanding of the problem:

Although cost-cutting is the only path to real healthcare reform, I don't believe that our politicians and the majority of voters will tolerate major reductions in healthcare expenditures including price caps. First of all, healthcare is the only viable industry in many small towns and even in large ones like Cleveland and Pittsburgh. Such cuts would result in fewer jobs. In addition, healthcare lobbyists will be showering money on legislators for their reelection campaigns. This will be very hard for them to turn down and will certainly influence large numbers of votes.
I suspect that the only major plank that will remain in the current healthcare reform agenda will be a government-sponsored health insurance plan (see: George F. Will: Obama's health care plan pushes Democrats' dependency agenda). I am not sure if the Democrats have the power and will to push such a program through in the face of a determined opposition.
If such a health insurance plan succeeds, the next initiative by the Democrats may be to try to provide such insurance to the nation's roughly 45 million uninsured. The cost of this will be in hundreds of billions of dollars. I believe that it will be proposed that the cost of such a major plan will be borne in part by new taxes, if that's politically possible. The balance will be added to the rapidly escalating federal deficit. This will cause additional opposition.
I don't think that screening preventive health measures for individuals will fall into disfavor simply because they are expensive. The more generous health plans will continue to cover them and many healthcare consumers will also be willing to pay for them out-of-pocket, if the charges for such services are judged to be reasonable and the outcomes impressive.

Placing Public Health Announcements on Google as Paid Ads

Bruce Friedman — 2009-06-19T23:59:00-04:00

Smartphones can be used as platforms for e-health campaigns (see: Making e-Health Information Accessible with Smart Phones, The Mobile Web and the Future of eHealth). It is also understood that healthcare consumers frequently turn to the web for health advice (see: Paging Dr. Google! We Are Waiting for a Second Opinion). Now comes news that the New York City Health Department was purchasing ad space on Google to disseminate information about the recent flu outbreak (see: NYC Health Dept. Buys Google Ads for Flu Searches). Below is an excerpt form the article with boldface emphasis mine:

When the [Wall Street Journal] Health Blog Googled “flu” this morning, we were surprised to see an ad for the New York City Health Department show up at the top of the search results page....So what’s a public-health agency doing buying search ads? We gave the health department a call to learn more, and got the skinny from Jeffrey Escoffier, director of health media and marketing....And people have continued to show up at the emergency room worried that they might have the swine flu, Escoffier said. So the department thought buying Google ads might be a way to direct people to the information they need online, to reduce calls to 311 and help people understand when it’s appropriate to seek medical care. The ads, which started running on Monday, only show up for people in the five boroughs. But they run on a bunch of different searches, including “H1N1″ and “swine.” So far, somewhere around 1,000 people a day have been clicking through on the ads, Escoffier said. He said the price varies by keyword, and couldn’t say how much the city has spent so far. We asked Escoffier if he thought his boss, NYC health commish Thomas Frieden, should take the idea of buying Google ads with him to his new job as head of the CDC. “It would be a good idea, I think,” he said. But a moment later he reconsidered. “CDC doesn’t need it,” he said. “Whenever you do a Google search, they show up on the first page.”

First of all, I think that purchasing ad space on Google provides an excellent communication channel for public service announcements including those relating to public health. I have no concern about the relatively minor cost of such ads which would probably yield a net savings for public health organization. People acquiring critical information on the web would not need to tie up the public health department's telephone lines. The placement of such ads can be tuned to only display for designated geographic areas and the cost for them would also be commensurately lower.

Of particular interest to me was the quote from the spokesperson from the New York City Health Department that the CDC would not need to place such Google ads for its critical messages because it had sufficient "Google juice" for high-level display on the Google search engine retrieval pages (SERP). I have posted previous notes about these specialized topics (see: Snap Google Quiz on a Tuesday Morning, Journalist Provides Advice about Search Engine Optimization). It's worthy of note that a director of health media and marketing for a public health agency would be this familiar with search engine optimization (SEO). It's a whole new world out there.

Much of Escalating Cost of Healthcare Due to Physician-Driven Overutilization

Bruce Friedman — 2009-06-18T23:00:00-04:00

A recent and widely-circulated article in the New Yorker by Atul Gawande (see: The Cost Conundrum) is casting unwanted attention on the physicians in McAllen, Texas. The article explores our ever-increasing healthcare costs using this small town as a lens. The central premise of this article, and one that I personally subscribe to, is that the high per capita Medicare costs in McAllen can be attributed to the "entrepreneurial" physicians who practice there. They have learned how to game Medicare by referring back and forth to each in other to generate professional fees. All of this is in the name of defensive medicine and quality care. It's legal but I am sure that they are not pleased with the attention that the article has drawn, particularly from the White House.

Needless to say, politicians from the high-cost Medicare states such as Senator John Kerry are now up-in-arms about this article and the conclusions that it draws (see: Health Care Spending Disparities Stir a Fight). The argument that they have dusted-off to discredit Gawande is that the data provided by the the Dartmouth Atlas Working Group (see: The Dartmouth Atlas of Health Care) and cited by him do not adequately take into account differing disease rates and severity across different geographic regions. Jonathan Skinner, a healthcare economist, easily defends Gawande's conclusions in a recent commentary (see: Is More Care Better Care?). Below is an excerpt from Skinner's article with boldface emphasis mine:

It is true that some regions of the country experience more illness than others, and of course sick people spend more on health care. To deal with this bias, the Dartmouth group has compared expenditures and frequency of treatment across regions for people with similar diseases. The most extensive study compared spending across regions using a variety of cohorts such as people who had suffered a hip fracture or heart-attack patients. This study examined people who were equally sick, whether they lived in Louisiana or Colorado. The researchers further adjusted for any differences in patient income, race, and prior health. They still found gaps of up to 60 percent in spending among regions. Most of the Dartmouth Atlas data hasn’t been adjusted to this degree, and so critics are right when they note that standard Atlas measures can’t always be compared between (say) healthy Oregon and unhealthy Louisiana. This is why Dr. Atul Gawande’s recent article in The New Yorker is so important, because he was careful to compare apples with apples: McAllen and El Paso, Tex. As he wrote, “[b]oth counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed.” Yet McAllen spends twice as much for each Medicare enrollee compared with El Paso. Why? In his visits to Texas, Dr. Gawande uncovered dramatic regional variations, evidently driven by a culture of profit-driven health care among doctors in McAllen.

I think that the McAllen docs whose style of practice has now been exposed, and their defenders across the country, now need to calm down and just take their medicine. The case is just too strong against them and their approach to medicine. Different utilization practices, whether well-intentioned or by design for personal enrichment, are a key element in our skyrocketing healthcare costs. A new system needs to be developed to rein them in but not harm patients. Every patient who comes to the Emergency Department does not need sophisticated brain imaging costing many thousands of dollars. However, we do need protocols to follow-up on these patients to identify the very rare individual who, in fact, does have a brain tumor. In other words, let's not launch a $50,000 workup for every patient who comes in the door of the ED with a common complaint.

A Clear and Simple Way for Employers to Cut Their Healthcare Costs

Bruce Friedman — 2009-06-17T23:59:00-04:00

I have published previous notes about the healthcare costs of chronic diseases and also notes about employer programs that reward employees for their participation in wellness programs (see, recently: Filling Out Health Questionnaires for Employers). A recent op-ed piece in the Wall Street Journal (see: How Safeway Is Cutting Health-Care Costs) by Steven Burd, CEO of Safeway, Inc., addresses these topics and was notable for both its clarity and direct approach to cutting healthcare costs. In his article, he makes reference to the very successful program that he has launched at his company. It should be noted that, addition to his CEO position, he is also the founder of the Coalition to Advance Healthcare Reform (CAHR). Below is an excerpt from the article with boldface emphasis mine:

At Safeway we believe that well-designed health-care reform, utilizing market-based solutions, can ultimately reduce our nation's health-care bill by 40%. The key to achieving these savings is health-care plans that reward healthy behavior....Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight...is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable....Currently we are focused on tobacco usage, healthy weight, blood pressure and cholesterol levels....Employees are tested for the four measures cited above and receive premium discounts off a "base level" premium for each test they pass. Data is collected by outside parties and not shared with company management. If they pass all four tests, annual premiums are reduced $780 for individuals and $1,560 for families. Should they fail any or all tests, they can be tested again in 12 months. If they pass or have made appropriate progress on something like obesity, the company provides a refund equal to the premium differences established at the beginning of the plan year....Our obesity and smoking rates are roughly 70% of the national average and our health-care costs for four years have been held constant. When surveyed, 78% of our employees rated our plan good, very good or excellent. In addition, 76% asked for more financial incentives to reward healthy behaviors.

The lion's share of healthcare costs are related to the treatment of cardiovascular disease, cancer, diabetes and obesity. All of these conditions can be avoided or ameliorated by the efforts of healthcare consumers themselves with a particular focus on tobacco usage, weight, blood pressure monitoring, and measuring cholesterol levels. These diseases can frequently be detected with health questionnaires, a simple physical exam, or a lab test.

No one would suggest that smoking cessation or weight loss programs are easy or universally effective. Nevertheless, a financial incentive to employees in the form of a refund on the healthcare insurance premium can be a powerful motivator for them. Most effective, of course, will be company sponsored professional weight-loss and smoking-cessation programs. One can't argue with the high level of support for the wellness program offered at Safeway demonstrated by employees. What I like most about this overall plan, as described above, is its simplicity and focus on the important components. It is probably relatively easy to administer for the company and to understand by the employees.