Wednesday, July 29, 2015

Empowering Consumers to Prevent Disease

Today I have 2 items on my reading list:

One, “How to User in a New Era of Preventive Health Care, by Elizabeth Holmes, founder and CEO of Theranos, a consumer health-technology and medical –laboratory services company, Wall Street Journal, July 29, 2015. In her piece, she states, “Laboratory tests drive 70% if all clinical decisions. They’re used to determine whether a patient should start taking medication and, if so, which one, They help doctors decide whether a patient should undergo medical procedures or be admitted to a hospital. And they’re used to identify an individual’s risk of developing health conditions such as diabetes or heart disease,” She concludes “ People should be able to get any lab test on their own. Waiting for symptoms to a doctor’s order may be too late.”

Two, the second is Start-Up Nation: Story of Israel’s Economic Miracle, by Dan Senor and Saul Singer, two journalists who report on the Middle East (A Council of Foreign Relations Book, 2009). The authors say of their book. “If there is one story that has been largely missed despite the extensive media coverage of Israel, it is that key economic metrics demonstrate Israel represents the greatest concentration of innovation and entrepreneurship in the world today.”

It might be argued that Silicon Valley, where Ms. Holmes hangs out, has an even greater concentration. The Obama administration has largely missed the power of innovation and entrepreneurship in reforming health care. CMS has an innovation center, but it mostly concentrates on developing Accountable Care Organizations and other organizational concepts that save the government money. And it levies a 2.3% tax on medical innovation companies’ profits.

I would like to pick up on Ms. Holmes idea and extend it.

Why not empower consumers to order their own battery of lab tests in a consumer-friendly setting, couple that order information with age, gender, vital signs and physical information (BP, pulse, weight, height, and blood Oxygen, and symptoms if any, and generate a report for consumer’s eyes only, using current available algorithms, to indicate the patients degree of health for their age and gender.

The report could be something called the Health Quotient ( normal range 75 to 125), the analogue of the IQ, and could indicate in plain language the state of their health, how to interpret the results, what to do if anything, and whether to consult with a physician. The consumer would own this report and could use it as a barometer of their health and whether it contains useful information to prevent disease. For this idea to work, consumers would have to be able to access the tests and vital data in accessible locations at an affordable price, which I believe could be in the $50 range. They could then use the report to present to their physician.

Sunday, July 26, 2015

Magnitude of U.S. Health Care

When you think of the magnitude of American health care, and old, healthy and sick, insured and uninsured, legal and illegal, employed and unemployed, rich and poor but mostly middle class.

America spends $3 trillion on health care, $9375 per person.

The government at CMS (Centers for Medicare and Medicaid), spends over $1 trillion for its Medicare 55 million and Medicaid programs 70 million, $8000 per enrollee.

Americans spend $1.05 trillion on hospital care, and $0.75 trillion on physician care.

Of the money spent, $1.5 trillion comes from government, $1.5 trillion from private sources, and government share is growing.
There are roughly 300,000 primary care physicians in U.S, one for every 100 citizens , and roughly 200,000 nurse practitioners and 100,000 physician assistants, with the numbers of these midlevel practitoners expected to double in next decade.

For U.S. citizens without ready access to primary care physicians, non-emergency room alternatives for routine care include retail clinics in pharmacy and grocery chains, 1900, one for every 16,800. Americans, and urgicare centers, 6400, one for every 5000 Americans. Most retail clinics and urgicenters are in heavily populated centers, not in rural areas.

Of total Americans employed, 9.0% are in health care, the largest single employment sector. One of every 8 Americans is employed in health care. Hospitals employ over 6 million Americans and over 200,000 physicians.

Saturday, July 25, 2015

What Will the ObamaCare Legacy Be?

When President Obama steps down in 2016, what will be the legacy of his signature domestic program? What will ObamaCare leave in its wake? What will be its lasting effects?

One, will it be consolidation of insurers and hospitals into giant entities
? Larry Robbins, who runs Glenview Capital Management LLC, a hedge fund, thinks so. In 2010, after ObamaCare passed, he and his partners bet the health care system was going to change, with more people gaining coverage, and insurers and hospital merging and gaining power to help government manage the new system. It was apparent government could not manage the system alone. Robbins and his partners began to invest in big insurers and big hospital systems and clung to their thesis that they system was going to change big time through two presidential campaigns, congressional shoot-outs, two midterm defeats for Democrats, and two Supreme Court cliffhangers.
Their bet has paid off handsomely. Only three giant insurers remain – United, Anthem-Cigna, and Aetna-Humana. Hospitals are merging into giant chains. Glenview now owns shares in seven huge health insurers and hospital operators with these values of holdings and year-to-date changes in stock price in 2015: Humana $926.7 million +28.6%, Tenet Heathcare, $863.6 +15.2%, Anthem $759.5 million +23.5%, Community Health Systems , $712.3 million +9.2% HCA Holdings, +27.2%, Aetna $395.2 million, +26.1%, and Cigna $274.6 +50.0%.

Legacy lessons? As big government grows bigger, it’s easier for government to manage and control the system through bigger players delivering the health care goods, namely big insurers and big hospitals. Consolidation, in other words, is the ObamaCare legacy endgame.

Two, will the legacy be growth in government coverage and decline in employer coverage? Will coverage of employees under ObamaCare, with its mandates that all workers be covered, all plans have comprehensive “essential” benefits, or suffer onerous penalties, and force employers to drop or shift risks by offering only high deductible health plans? This is not only possible but probable. Since 2005, the percentage change in annual enrollment by coverage type has been;

• Medicaid, + 52.2%, 69.7 million people

• Medicare, + 31.1%, 54.1 million people

• Individual, including Medicare supplemental and health exchange plans, +25.4%, 25.2 million.

• Employer sponsored plans, -3.5%, 172 million

In other words, government sponsored and mandated plans dominate U.S. health care and are the fastest growing health market segment.

Three, will big government break the back of the medical profession by consolidating it and by deemphasizing autonomy and minimizing personal individual patient attention and cutting fee-for-service reimbursement by transforming to a system based on “value,” i.e, managerial and computer-judged population outcomes geared to lower prices as managed by teams using big data and online algorithms paying for by bundled services across the continuum of care?

Four , will the legacy be further fragmentation of the system with government controlled clinics, retail clinics, hospital-owned urgent care centers and other decentralized outpatient facilities, and private physicians in consumer-focused outpatient diagnostic and treatment centers, offering convenience and greater consumer satisfaction and fighting for market share in a two-tier health system, designed for those who can pay or not pay?

Five, or is it possible that ObamaCare will falter and break up in the shoals and on the shores of economic and reality
because of broken ObamaCare promises, out-0f-control costs, loss of patient choice and freedom, public distrust, and political defeats at the presidential and congressional ballot boxes?

Only one thing is certain. The Republicans cannot beat something, ObamaCare, with nothing, complaints and criticism of ObamaCare, without a unified alternative that covers more people at less cost with more choice.

Six, will it be all of the above, implemented in one way or another?
Probably, and maybe that’s the way it ought to be in a multicultural democracy that desires individual choice, quality options, and personal freedom with privacy.

Thursday, July 23, 2015

Physician Pride and Autonomy

That the Accountable Care Act has wounded the pride of doctors and eroded their autonomy there is little doubt. Patients with primary care physicians are flocking to retail clinics staffed by nurse practitioners and physician assistants and to urgent care centers when they have no primary care doctor. Politicians are saying only the government, not physicians, can be trusted to deliver care. Doctors are rushing into hospital employment because they cannot afford to maintain private practices because of low reimbursement and government regulations . Americans are being told that only comparative data generated by computers can be trusted, not clinical judgment and experience, as a basis for paying physicians and judging “value” of services. Doctors are being replaced by nurse practitioners and physician assistants, or teams of other care professionals, to provide “coordinated care across the continuum.”

To make matters worse, there is no unifying national organization representing physicians to respond to these challenges to physician pride and autonomy. The American Medical Association is no longer respected and has declining membership. Organizations like Sermo, the Physicians Foundation, medical societies and academies represent different physician constituencies, and groups like the American Association of Physicians and Surgeons, or the Free Market Medical Association are regarded as too conservative.

The American public is confused. They consistently disapprove of ObamaCare, usually by double digit margins. They want to see a doctor but are having a hard time finding one. More than one-third are now enrolled in Medicare (55 million), Medicaid (70 million), health exchange plans (10 million), and at least one half receive government benefits in one form or another the VA, food stamps, disability payments, Social Security.

It is in this setting that a new physician organization, the United Physicians and Surgeons Association (UPSA), has been formed to address physicians dilemmas. UPSA will meet in Keystone, Colorado, on July 24-26 at a physician summit meeting to consider physician options and how to respond to ObamaCare, which appears to be here to stay, to bundled payments for episodes of care rather than fee-for-service, to declining physician reimbursements and regulations, to online virtual relationships between patients and doctors, to the constraints of hospital employment and its high costs for patients, to walk-in clinics as an option to physician office visits, to how to use new social media and mobile device innovations to improve care and convenience and market their services, to market -based alternatives, such as direct ambulatory primary and surgical care devoid of 3rd party involvement, to and high deductible savings accounts, in which patient mus pay up to the amount of the deductible. In the age of a rapid changing culture in which physicians are considered as just another market commodity, and which are sometimes viewed with irreverence, there is no single magical answer to these various challenges. Thee are only niches to be filled, and alternative consumer-friendly markets to be developed.
Convenient Ambulatory Retail Care

If you have any interest in the powerful expansion of retail ambulatory care, as delivered by nurse practitioners and physician assistants in pharmacy and supermarkets, I invite you to read two articles in the July 23 issue of the New England Journal of Medicine:

“The Expansion of Retail Clinics- Corporate Titans vs.Organized Medicine,” by J.K. Iglehart, national correspondent for the Journal.

“Convenient Ambulatory Care – Promise, Pittfalls, and Policy, “ by three authors from the New York City and Health and Hospitals Corporation.

The articles messages are unmistakable: walk-in clinics in pharmacies and supermarkets, now numbering 1900 and owned by corporations and staffed by nurse practitioners and physician assistants, and walk-in clinics, 6400 of them, staffed by family physician and emergency room physicians, and owned by various health care entities, are growing like topsy.

Together ambulatory care setting visits account of one third of health care spending. Why the rapid growth of wall-in clinics? The reasons are varied, but walk-in clinics appeal to health care consumers. They can expected lower prices, extended hours, to be seen immediately, low-acuity care, immunizations, some preventive care, and insurance coverage, and they do not require a primary care physician to get care.

Here are the main players in the commercial market.

CVS, clinic name – MinuteClinic, 980 clinics

Walgreens, clinic name – Heslthcare Clinic, 400 clinics

Kroger, clinic name – the Little Clinic, 159 clinics

Target, clinic name – Target Clinic, 80 clinics (on June 15, 2015, CVS acquired Target pharmacies and clinics, which will be rebranded as MInuteclinics)

Most of these clinics share information and referrals with primary care physicians. Urgent care centers have relationships with health care organizations such as EpicCare, various proprietary hospital system, eClinicalWorks, or Athenahealth.

Walmart’s is also in the ambulatory game. The huge retail chain has announced it will operate “Walmart Care Clinics,” in conjunction with QuadMed to arrange for community-based physicians to provide clinic oversight. Walmart now runs 17 clinics in Texas, South Carolina, and Georgia.

Overall, CVS with 7600 stores, WalGreens with 8200 stores and Walmart with 4500 stores, have plenty of room for expansion of retail clinics.

A number of medical organizations – the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics have questioned retail clinics quality of care. The Academy of Pediatrics have been the most strident, saying retail clinics are an “inappropriate source of primary care for children because they fragment children’s health care and do not support the medical home.”

According to J. Hwang and Mehrotra, writing in the Harvard Business Review in 2013, retail clinics, despite their rapid growth, have failed to transform health care because of regulatory and reimbursement barriers. Nevertheless Iglehart observes, “changes in policy under the ACA, a loosening of state restrictions on nurse practitioners’ practice, and the movement toward value-based car won’t erase all the obstacles facing retail clinics, but the train has definitely left the station.” Whether retail clinics will contribute to the ACA “train wreck,” a term coined by Max Baucus, former Democratic senator from Montana and now ambassador to China, or transform health care is for history to judge.
What Experts Predict about Health Care Future

Experts, it is said, are someone from out of town who knows more and more about less and less until they know everything about nothing. Experts cannot predict the future because it involves the future. Keep these truisms in mind as you read these predictions about the future of health care from 10 well-known and respected health care futurists as presented in the July 21 Wall Street Journal, "The Future of Health Care: The Experts."

As I read their predictions, I thought of Edward De Bono, an English physician who runs a think tank for experts on the Island of Malta. De Bono has said the healthcare landscape is composed of a series of vertical holes, which hospitals, academic centers, and specialists inhabit. At the bottom of each vertical hole resides a collection of world class experts. The only problem, observed De Bono, is that the holes are not interconnected.

The present crop of experts are not in holes. They are hovering over the health care landscape. They have new tools - the Internet, social media, and mobile devices – that they believe will allow them to connect the holes, for better or worse.

Here are 10 of their predictions, as set forth in the July 21 edition of the Wall Street Journal “The Future of Health Care: The Experts.

1. John Sotos cardiologist, flight surgeon, and CEO of Expertscape. com. “How Future Hackers Will Target Your DNA.” Expert hackers will design DNA sequences that will spread DNA viruses from person to person that will allow hackers to redesign the human race into species they favor – redheads, whites, blacks, members of the British Royal family. DNA, notes Sotos, is nothing more or less than a programming language for living tissue. The human genome therefor is vulnerable to hackers. Our only defense against social engineering hackers is to build a cadre of experts to defend against them..

2. David Blumenthal, MD, president of the Commonwealth Fund, “What Health Care Will Look Like in 2013. Maybe.” Mobile devices will make health care better, more convenient, and cheaper. Maybe, if certain problems are resolved – preserving the privacy of personal data, making sure various devices and websites can be made to talk to one another, and bridging philosophical gaps between government elites and marketing experts.

3.Marc Agronine, MD, a geriatric psychiatrist in Miami, “The Nursing Care of the Future Will Be in Our Homes.” Home care services of every kind will be possible with wireless wearables and mobile devices that provide data on vital signs, metabolic indices, home safety, and daily needs. Many of these devices will be voice-activated. Most will be under the patient’s control and will monitor, track, and engage patients in innumerable ways even if the patient is computer illiterate and no matter what their mindset or capabilities.

4.Robert Wachter, MD, professor at the department of medicine at the University of California in San Francisco, “How Technology Will Change the Doctor/Patient Relationship,” Telemedicine and technology will transform these relationships at the level of patient stays and visits to hospitals, doctor visits, and emergency rooms, transforming many of these relationships into virtual visits over the net. The problem will be making sense of it all. Treatment will be customized to the fit patient needs based on gene analysis, risk factors, and the real-time monitoring of hundreds of thousands of similar. patients will similar problems.
5.Gur Dhal, MD, professor of medicine at the University of California, “How Technology Won’t Change the Doctor/Patient Relationship.” Twenty years from now, medical practice will focus on 3 tasks: 1) discovery of the unique manifestations of a single patient; 2) searches on the Internet for diagnosis and treatment of these individual characteristics; 3) improvements of a plan for care in spite of the unwieldy nature of our health system. Interactions of doctors and patients will remain pretty much the same but will change the nature of the conversation by narrowing the knowledge gap between doctors and patients.

6. Molly Mettler, Senior of Missions at “ A Personalized Owner’s Manual for Your Health Care,” We will have a totally personal, totally interpretive owner’s manual to access health care patient records and a patient’s personal health care record. It will focus on your health goals, will be lifelong, and individualized to give you access to unlimited information, and to understand your complete health care .

7. Drew Harris, MD, Director of Health Policy at Thomas Jefferson University School of Population Health, “How Big Data Will Customize Your Health Care,” Fear not for the future of your health. Big Data in wearable devices will track where you go, what you eat, what you do, and how we sleep in real time. But we must use this data and control it so as not to impinge on individual liberties and make sure the data system is unhackable. So far the government has proven impotent in warding off hackers. Hackers has stolen data in 21 million government workers.

8. Madly Dychtwald, author and co-founder of Age Wave, “A Vision of the Future Free of Alzheimers,” By 2015 we will be well on the track of preventing and ending Alzheimers, that dread that results in senility of 5 million Americans. We will do this through advances in technology, that reduce or dissolve amyloid plaques that short circuit normal synapses. When Alzheimers no longer exists 1) half of nursing home beds will be emptied 2) tens of millions of caregivers will be unshackled; 3) money now going into Alzheimers research will be freed up to pursue cures for other diseases; 4) Alzheimers patients will be able to lead independent lives; 5) fears of a longer life without dementia will be realized.

9. Leah Binder, President and CEO of the Leapfrog Group. “What Hospital Websites Will Look Like,” High Deductible Health Plans (HDHPs) will transform the health care landscape and radically change health consumer behavior. Patients will shop for care, compare costs, seek out what hospitals have to offer, rate the quality of hospitals, have unlimited access to hospital pricing structures, consider hospital special offers, and rate the food and amenities offered by various hospitals.
10. Susan Devoe, President and CEO of Premier Inc, a health care organization representing 3000 community hospitals, “What Future Hospitals Will Look Like,” Hospitals will consists of an interconnected network of hospitals, doctors, and other providers provided coordinated care across the continuum of care. The network will bring together primary care physicians, specialists, post-acute care facilities, and pharmacy, nutrition, and wellness coaches – all available for managing outcomes and total costs will be lowered by bundling care, each provider or group of providers being paid on a sliding scale based on the effectiveness of the organization in achieving its outcome goals.

So much for utopian predictions, based too much, in my opinion, on the dependence of data, social media, and wearable and implanted devices to be the be-all and end-all and measure-all of future health care. There is no such thing as total transparency, total prevention, or total cures. But one can always hope and have big dreams and big goals. If even half are achieved, it will be worth the effort.