Navigating Healthcare – Patient Safety and Personal Healthcare Management

Medical Education Broken Economic Model

Posted in Uncategorized by drnic on June 25, 2017

Medical Education Costs

I posted an article this past week featuring an article from CBS Moneywatch in 2013: $1 million mistake: Becoming a doctor that generated a few comments including comments about clinician burn out domestically and internationally and some questions about the current status and if this was getting worse or better.

Other Countries

It would seem that this problem is worse and spreading. Some countries that used to pay for higher education of doctors – the UK would have been one of those no longer do. Some time back they introduced fees that run to 9,000 GBP per year for 5 years

That’s $ 58,000 for the 5 years

– about the same as 1 years tuition in a US medical school => 1/4 the cost of medical school in the US

(Those fees rise dramatically to 39,000 GBP per term for over seas students)

There are wide variations and this article on the Student Doctor Network site: Attending Medical School on Foreign Ground offers some insights into the variations

The cost of attending medical school varies widely both inside and outside the U.S. Once tuition, fees, and the cost of living are figured in, American private schools come in on the high end of the scale and state colleges land in the middle. Average medical student debt ranges from $70K for medical students in Poland to $200K for medical students in Australia and Ireland.

  • Nearly 90% of U.S. student loans for medical schools outside the U.S. go to Caribbean medical schools, popular for proximity to home, tropical beach locations, and reasonable cost, which compares favorably to the mid-range schools in the U.S.
  • Medical schools in Mexico are cheap and so is the cost of living, but the high crime rate must also be taken into consideration.
  • Canada might be an appealing low-cost option if prospective Canadian med students were not saddled with similar issues faced by those in the U.S., more aspirants than programs.
  • The cost of attending schools in Europe range from very inexpensive Poland to astronomical prestigious schools such as St. Andrews University in Ireland…which costs over $250K in tuition alone, but comes with guaranteed admission to the University of Edinburgh for post-graduate studies.
  • The average student expenses in the Middle East are comparably low, but there are cultural and language hurdles.

Cost of Attendance

For clinicians delivering the care, all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors its persistence and endurance that win out. The barriers to entry are high and tied to economics. If you manage to complete your first degree at a conservative estimate of $40,000 only then are you ready to apply to medical schools and that’s going to put you in debt to the tune of $240,000 or so. Taken together that is at least $280,000 of debt hanging over your shoulder when you conservatively emerge as a qualified doctor aged 26 with at least another 3-4 years on average of low-income work while you finish your apprenticeship as a resident. So by the time you are fully qualified and ready to start serving the public and doing the work you originally signed dup to do when you set your sights on medicine you lost 12 years of time to earn an income and accused a debt of $280,000. At age 30 this equates to a repayment (calculated based on the current educational loan rates averaged out of 5.31%) is a monthly payment of

  • 10 year repayment $3,012
  • 20 year repayment $1,896
  • 30 year repayment $1,556

 

Lost Earning Potential

This lost income earning opportunity that is a minimum of 8 years in the US – 4 years for an undergraduate degree and 4 years in medical school. Add in a few years of post-graduate training, required to enter any specialty and you have a decade of lost income that at an average salary of $50,000 equates to a cool half a million dollars. Paying off the debt with interest pile on the burden and put newly minted doctors at least a $1,000,000 in the hole before they even start thinking about a family and a life.

Our clinical professionals all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and the post qualification economics drive them towards higher paying specialties to help ease the debt burden and are certain contributors to the high run our rates and extreme levels of dissatisfaction with the career of medicine.

How do we Fix Medical Education Economics

There are some programs attempting to address this by steering newly qualified doctors to under served areas with a promise of paying off outstanding loans after 10 years of time committed to these areas. What to do about the fundamental issue for the many already saddled with this debt and struggling to find a path and how do we change rebalance the system? Given the reports that suggest the looming dearth of doctors available to treat the exploding populations – something that is amplified in many other parts of the world where there are many fewer doctors per head of population than we have here in the United States.

Its and urgent problem and one that I see few solutions or paths – do you have any ideas. Are there are simple incremental changes we could make that might start to move the needle and change this system to attract and support the type of doctors and clinicians we want treating patients. Is there an incremental change that could be applied to shift the cost of education or change the outcome that pushes so many into specialization when we need internists and family practitioners. Is it as simple as increasing the salaries/rates of pay for the specialties we want to encourage doctors to enter?

Leave your thoughts and comments below – I’d love to hear your ideas.

Healthcare – Its Personal

The Great Healthcare Debate

Healthcare is personal and front and center in our minds not just because we all intersect with it in some way but it employs 1 in 9 people in the United States. With the current state of our media and political system with polarized debates, he said she said talking heads on the media, the echo chamber of social media and the 24/7/365 barrage of news and fake news it can be hard to see a pathway out of the quagmire we find ourselves in. But we all want to see that path. I just don’t believe that people get up in the morning wondering how they can decimate the healthcare services and the lives of their fellow human beings. We don’t get up out of bed every day wondering how best to punish people who may have made bad choices in their lives or who find themselves in unfortunate positions though geography (the zip code effect) or genetics. I know I don’t and I don’t think you do either.

Yet the stream of coverage and what we read, see and hear online and sometimes even in person suggests that this is the case. I can’t answer the reasons why but I’ve read a string of articles and reporting that variably suggests its always been like this to this is the fault – and then insert the name of your favorite whipping horse. Ultimately it does not matter – unless you believe that people wake up with malintent every morning it’s better to start with an understanding of the problem and then thinking about possible solutions and how we can apply them quickly and effectively

So Let’s Start with some of the fundamental problems in our healthcare system – to be clear we are not alone in the world. I have seen and heard from many others in different countries who are all struggling to varying degrees and with different focus and priorities the same issues. If I had to boil it down to one issue I would say

Limited Resources and the Prioritization of the Allocation of those resources

It’s a familiar equation to anyone trying to balance their budget or allocate their time. If you are like me you may find there are just not enough hours in the day for the task list you created in the morning and wishing either to stretch time (time dilation) or perhaps be able to turn time back with the Wizarding world’s  Time Turner. There are two basic options available – reduce the inputs or reduce the outputs. In the vernacular of budgeting – either spend less or make more money. Both may be viable and depend on personal circumstance but undoubtedly there will be easier and harder solutions. Ultimately we all have to make our own personal decisions – so one solution or size does not fit all.

Photo from jenga.com

It would be foolish to suggest that this covers all the complexity of the healthcare system as we all know healthcare is incredibly complex and always reminds me of the game Jenga.

 

This does not cover everything and there are many other elements in play but it is certainly a start and one that individuals and organizations can focus on to start to make incremental improvements.

As one Chinese proverb states:

Every journey starts with a single step

And turning that step into a habit is one of the best ways of setting a path to improvement.

Demand Side of Healthcare

This is the access and use of the system and the burden does not just fall on the individual. But it does start there as it is out personal choices to access and use available services that creates demand. Historically in the United States, the cost and payment of this access have been disassociated from the individual. When you visit the doctor or pharmacy you don’t pay the actual cost of the service – your insurance carrier does. Ultimately we do all pay for this through our insurance premiums and for many the contributions made on our behalf by our employer that is part of the compensation we receive for working for them but at the point of care, we are disconnected from the price and cost of a service.

Patient Accessing Care

To a varying degree individuals have some form of co-pay – a personal cost that is defined by the insurance coverage and is shifting increasingly to the individual under the new insurance plans called High Deductible Health Plans (HDHP). One of the intentions of this policy is to make the individual responsible for this cost in an attempt to influence behavior and decrease unnecessary access. But this comes with the inevitable unintended consequences with cost avoidance strategies by individuals who knowing they will be held responsible for the full cost of a visit, drug or test may elect to decline to have or use the service.

 

I’d count myself in that crowd having been on a HDHP plan for several years. I can point to several decision where I have declined tests, treatment and access to care because of the nature of my personal responsibility – I have an associated health savings account (HSA) which should cover the capped amount of cost for the year. But the crippling nature of potential costs associated with a catastrophic medical problem – a serious accident, cancer, heart attack are all so terrifying that I see the HSA as a buffer against the potential of medical insolvency that might result especially when you consider the impact on a family with one source of income that would be impacted by any medical disability.

 

Insurers Paying for Care

Insurers want to reduce their costs – and even the non-profits have to make money so are focused on the bottom line if they want to continue to serve their customers and population. So they look to find ways to reduce the unnecessary access to care imposing barriers and limits. There was a gate keeper concept that requires a referral letter from a primary care physician before you can access s specialist – that service by the way costing you additional fees to see the primary care provider. There are formulary requirements that exclude certain drugs from coverage and attempts to limit access to specific doctors and networks to strengthen the buying and negotiation power of the payor with the providers in the system.

 

Providers Delivering Care

On the provider side the clinal professionals delivering the care all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors, it’s persistence and endurance that win out. The barriers to entry are high and tied to economics. They all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and they have bills to pay both for their education but also the infrastructure they must use to be able to both deliver care but also bill and be paid for delivering. They want to reduce their overhead and spend as much of their time and resources on the delivery of care but to survive in the system must allocate significant amounts of money to non-clinal systems and activities. Estimates of these costs suggest that at least 30% of the healthcare costs we as a society pay in the United States are tied to administrative and billing functions. The data’s still lagging but projections for 2016 put the total healthcare bill at $3.207 Trillion (thats $3,207,000,000,000 or more than $10,000 per person in the USA)

Healthcare Administrative Cost: $962 Billion Dollars

$962,100,000,000

 

Reconciling the Differences

Credit Imgur

The difference of opinion often centers on what is unnecessary – in the eyes of the patient they need and want the care they think is appropriate to them. Some of this is fed by a constant stream of information that even for an well informed clinically experienced specialist can be difficult to comprehend and make informed decision. We want wants best for our personal health and the health of our family and loved ones. But sometimes what the patient may think is best may not be – a great example is the steady stream of requests for antibiotics for treatments of minor infections. Not every sore throat or cough demands the use of antibiotics and in fact, in many cases, their use is damaging as we face a future where this line of defense is increasingly being overrun with smartly adaptive bacteria who develop resistance with terrifying speed.

 

Payors Perspectives

The same is true of payor and insurers – they face a rising tide of costs associated with care that is increasingly complicated and expensive and struggle to balance their budget.Faced with one patient who’s costs for treatment might be hundreds of thousands of dollars or more so they limit or decline this in favor of treating multiple other patients where their cost of treatment is thousands of dollars or less? The utopian answer is treat everyone but we they like each of us do not have unlimited budget or resources and have to make hard decisions. And the problem with healthcare fundedfor the population but access individually.

 

Healthcare is funded for the population but access individually

 

Clinicians Perspectives

Clinicians also have a view on what’s appropriate – and the vast majority act with total integrity (I would like to say all of them but sadly there are occasional stories of clinicians and healthcare professionals who game the system – sometimes with simple prescription based fraud or other times over treatment of stenting in cardiac cases). Sadly for a profession that is so dependent on trust the rare cases of fraud and abuse unfairly tar everyone with the same brush. As I said above – I believe everyone gets up in the morning with the best intentions and this is true of the clinal professionals who each and every day battle a system to deliver the care and compassion they set out to deliver when they took the path into healthcare. They want to say no to unnecessary treatment but the personal pressures applied and the underlying compassion and the innate drive that was the foundation of why they entered the profession can influence them to order and prescribe because they are unable to explain the lack of value and offering this option makes their patient happier and comfortable.

So how do we reconcile these differing opinions

 

Economics and Making Choices

Which path is best

There’s a sad fact in the US healthcare system – we do not talk about cost effectiveness. Its not just a taboo subject but also a forbidden topic, As Aaron Carroll (The Incidental Economist) noted in his piece Forbidden Topic in Health Policy Debate: Cost Effectiveness we avoid talking about cost-effectiveness in the United States.

Some think that discussing cost effectiveness puts us on the slippery slope to rationing, or even “death panels.”

As he points out – if there was a pill available that could extend your life by one day but costs a billion dollars, most would accept this as an unacceptable trade off and decline it. But that’ extreme – as you decrease the cost where does that line become blurred?

what’s to stop us from deciding that spending a couple hundred thousand dollars to extend grandma’s life for a year isn’t worth it either?

More troubling is the shackles that have been placed on the Patient Centered Outcomes Research Institute – who were founded but explicitly prohibited it from funding any cost-effectiveness research at all! How can an outcomes institute assess healthcare if cost effectiveness is not part of the equation?

“We don’t consider cost effectiveness to be an outcome of direct importance to patients.”

In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website,

PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the healthcare choices they face every day, guided by those who will use that information.

 

Quality-Adjusted Life Years

As he points out there is actually a fairly robust strategy and measure that can offer insights into the value of measuring health outcomes – QALY’s (Quality-Adjusted Life Years) which the National Health Service has been using fro some time in the National Institute for Health and Care Excellence (NICE) that provides guidance, advice, quality standards and information services for health, public health and social care. Also contains resources to help maximise use of evidence and guidance. There is no doubt they are imperfect but very little in life is perfect and perfection should not be a barrier to progress. The use of this is not a sole determinant – but offers some measure of science and data to making what are incredibly difficult tdecisions

So in the current debate of what health system we need to put in place I would advocate the inclusion of cost effectiveness as one of the factors that must be considered and the QALY and perhaps even the Incremental cost-effectiveness ratio (ICER) as part of this difficult discussion.

I’m all about incremental changes and while including a cost effectiveness as a measure may seem a bigger stretch I feel it is a smaller step in the right direction. Can we achieve this? Is there a better incremental step we can take to resolve the challenges of our healthcare system? Leave your thoughts below.

Healthcare – Its Personal was originally published on Dr Nick – The Incrementalist

May the Fourth be With You

It’s the artificial holiday that celebrates the play on words from Star Wars movies – a rallying cry

The list of suggested actions from the Starwars site may not be to everyone’s taste and includes everything from

  • Holding movie marathons
  • Dress up as a Star Wars Character
  • Star wars food including blue milk!
  • Getting a Star Wars Tattoo

 

But this year I follow Yoda’s advice:

“Pass on what you have learned”

Specialty Pharmacy

This year I attended the Asembia Specialty Pharmacy Summit held this time each year in Vegas at the Wynn/Encore resort. This is the largest conference for specialty pharmacy but as Alex Fine noted and I agreed –

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All pharmacy is moving rapidly in the direction of specialty as we head into a world filled with precision medicine customized to the individual. On the one hand, this is an exciting proposition – at least to me. I am always reminded of the great scene in Monty Python’s Life of Brian

You are all individuals…..we are but medicine has not treated us that way. Historically the path to understanding disease was based on grouping patients, diseases, signs, and symptoms into logical groups that helped decode underlying cases of a disease.Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted). This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.

Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted).

This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.

From: http://sandwalk.blogspot.com/2016/02/happy-birthday-human-genome-sequence.html

Over the course of the last few years, we have seen a clear move towards the individualized understanding of patients and disease accompanied by the inclusion of patients (Patient Engagement).

Patient Engagement and Access

There was a clear theme in the messages from various presenters that offered a clear vision of the push towards the consumer and patient engagement and a clear desire to find a path to delivering access to everyone that was captured by Liz Barrett from Pfizer in her keynote presentation and summarized with her slide – The 4 Tenets for Healthcare:

Access to quality
Incentives
Long-Term Value
Competitive principles

Providing access that overcomes the current challenges but builds in incentives for everyone in the system – not just the providers and hospitals but also patients and everyone involved in healthcare. This is the principle of competition without which systems tend to decline and ultimately stop working. There are people who perceive competition and capital principles as contraindicated in healthcare that we want to provide to everyone. I think these ideals can and should co-exist – without competition motivation disappears and efficiency will decline.

To achieve this we should take a book out of Yoda’s wisdom to pass on this wisdom and my key message for this day. Benefiting from the extended community. Our ability to connect and access people and resources has never been better. The need to remember data is much reduced:

GIYF

This access goes far beyond the data and to people and resources. Can you imagine making a purchase without looking at ratings and reviews on sites – I can’t. Yet the reviews are from people I don’t know and have not met – yet I trust them. This works because of the human desire to help others (this, by the way, is the reason that social engineering as carried out by hackers is so successful – this will be the subject of a post coming up in the future). But this creates an incredible set of resources and talent available to you.

Patient Communities

Some of it is formalized like the early website entry in this area: Patients Like Me. But extends to informal interactions on social media channels like facebook and one of my favorite: Paying till it Hurts. Then there is your extended family and friends who all want to help. You will find people who have been through similar experiences, will have tips and ideas on how to deal with problems that others have faced and have conquered

I was lucky to hear Arnold Schwarzenegger present as the keynote at this recent conference – his recurring theme was that he was not a self-made man but his success was the result of all the help and support he received from others

So use the power of the Force – it is your network, your friends, family and those around you.

Derive strength from them, have them provide tips on what small changes you can make to improve your health and then help keep you on track – nothing like knowing that you are being watched to help keep you on track.

One of my most successful personal health drives was base don a weekly self-reported weigh in for myself and two colleagues. Anytime I felt I was going to make a poor choice on food or exercise I just thought of the weekly chart and where my line would be relative to my colleagues and I did not want to be the outlier.

Have you had success helping friends and family? What works and what doesn’t. Is there a special trick or insight you could share that might help someone else – share it now and help the community.

 

May the Fourth be With You was originally published on Dr Nick – The Incrementalist

World Malaria Day 2017

Posted in Africa, DigitalHealth, Healthcare Technology, Innovation by drnic on April 25, 2017

Malaria

 

World Malaria day is today – Tuesday, April 25, 2017. Recognizing global efforts to control and perhaps one day eradicate this major killer that disproportionately affects my home country of Africa.

The WHO African Region continues to shoulder the heaviest malaria burden, accounting for an estimated 90% of malaria cases and 92% of malaria deaths in 2015. The WHO South-East Asia Region accounted for 7% of global malaria cases and 6% of malaria deaths. Three quarters of these cases and deaths are estimated to have occurred in fewer than 15 countries, with Nigeria and Democratic Republic of the Congo accounting for more than a third

 

Status of Malaria Today

Based on the WHO 2016 Malaria report there were 212 Million cases globally of Malaria. While we have seen some great progress with a decrease in Malaria infection rate between 2010 and 2015 of 21% and a decrease in the mortality rate of 29% we have a long way to go. Almost Half the population of the world is at risk from Malaria, and in 2015 an estimated 429,000 people died from Malaria. That’s the whole population of Miami dining every year.

Source: Marc Averette

More than 2/3 of the deaths that occur in children under the age of 5 and pregnant women are really susceptible – that’s a double hit on vulnerable populations.

The lifecycle encompasses the mosquito as carriers and transmission to humans. This is a great graphic summarizing the

 

 

Prevention and Treatment

The basis of prevention and treatment is tied to 3 basic methods

  • Insecticides and Mosquito Nets
  • Indoor spraying of insecticides
  • Preventative Therapies for pregnant women, children and infants in Africa

 

The good news is that advances in Digital Health and mobile technologies that are bringing testing capabilities to many remote and underserved areas. Testing rates of suspected malaria cases have increased from 40% in 2010 to 76% in 2015 much of it due to rapid testing capabilities that economical and are increasingly available.

Sadly despite the progress, some of the mainstays of prevention and treatment are being impacted by the emergence of insecticide and drug resistance that has seen 60 countries reporting resistance to at least one of the 4 classes of insecticides and even more troubling 5 countries have reported drug resistance to the core compound used in antimalarials artemisinin

 

 

The report card by country is a mixed bag with some progress and success but increases in incidence in other areas

Many organizations have been working hard in this area and that includes the work by the Bill and Melinda Gates foundation has been focusing for many years on a World free of Malaria. They have invested over $2 Billion in grants spread across multiple areas prevention, mitigation and treatment.

Current Problems

Its a tricky virus that uses all sorts of clever subterfuge to fooling our bodies and the other carriers into ignoring the infection. There is even a clever “bending” of the red cell wall to allow the virus to enter more easily as demonstrated at Imperial College – Malaria parasites soften our cells’ defenses in order to invade:

However, now researchers led by a team at Imperial College London have found that the parasites also change the properties of red cells in a way that helps them achieve cell entry. The results are published in Proceedings of the National Academy of Sciences.

There are many fronts open and Papua New Guinea are one of the countries that dare to hope with encouraging progress that may bring about the end to the disease

In PNG, control measures – in particular the rollout of long-lasting, insecticide-treated bed nets – have resulted in the prevalence of malaria declining by more than 80% across the country since 2009. Cases reported at four sentinel sites have dropped from 205 to 48 per 1,000, surpassing all expectations.

 

New Strategies in Treatment of Malaria

There has been a lot of work on Vaccines for Malaria and it would appear some successful studies including this one from Germany

University of Tübingen researchers in collaboration with the biotech company Sanaria Inc. have demonstrated in a clinical trial that a new vaccine for malaria called Sanaria® PfSPZ-CVac has been up to 100 percent effective when assessed at 10 weeks after the last dose of vaccine.

So perhaps like Dengue – it may be “The Beginning of the End”. Let’s not let up – this is a major killer. Even with prevention and mitigation therapy as expatriates living overseas in Malaria ridden areas my mother still contracted the disease. We have had a global eradication program in action since the 1950’s – with advancement in science and understanding perhaps we are finally on the cusp of eradication?

You can find out more here and download the Infographic: Malaria Can Be Defeated

 

World Malaria Day 2017 was originally published on Dr Nick – The Incrementalist

Patient Centered Systems

What will it take to move our healthcare system to a truly patient-centered system? We know based on multiple data points that engaged patients have a big impact on the successful outcome of treatment. Leonard Kish cited the phrase back in 2012

Patient Engagement is the Blockbuster Drug of the Century

Referencing a 2009 Kaiser study of coordinated cardiac care and comparing to those not enrolled in the study

“patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.”

“clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.”

And this study in Telemedicine and e-Health. Dec 2008; Vol.14 (10): 1118-1126 that showed impressive results for chronic disease management:

  • 19.74% reduction in hospital admissions
  • 25.31% reduction in bed days of care
  • 86% patient satisfaction
  • $1,600 average cost per patient per year, compared to $13,121 for primary care and $77,745 for nursing home care
  • 20% to 57% reduction in the need to be treated for the chronic diseases studied, including diabetes, COPD, heart failure, PTSD, and depression

 

Patient Data Ownership

I believe as do many others that the patient is at the center of everything we do and deliver in healthcare. By placing the patient and their information at the center of care and allowing them access and control we empower them and enable a model that moves away from the historical paternalistic delivery of healthcare to patient-centered and enabled care. It does come with challenges since many people contribute to that care and the current administrative and financial configuration focus the management and ownership of data with providers, healthcare systems and payors. While many patients want access to their data and some even want to own and manage it, many do not and are ill equipped to be responsible for this data. Perhaps what we need are some independent services and providers who aggregate, manage, secure and maintain patient data on behalf of patients – much as banks do with our money. There was some hope when Google and Microsoft jumped into healthcare offering Google Health and Microsoft Health Vault respectively. Microsoft’s version continues to this day – google withdrew theirs and Sergey Brin was widely quoted when he said

“Generally, health is just so heavily regulated. It’s just a painful business to be in, I think the regulatory burden in the US is so high that think it would dissuade a lot of entrepreneurs.”

But while complex, not insurmountable and as he rightly points out

“I am really excited about the possibility of data also, to improve health”

I am too and while there remain many challenges associated with securing and sharing that data the “entrance” of these alternative participants into the healthcare space – some perhaps looking at this from a simple employee perspective, is an opportunity for new ideas, insights, and people applying the collective brain power to one of our most pressing problems. I continue to hear from colleagues and friends of companies that are exploring and looking at healthcare. UPS highlighted their healthcare focus and the potential for 3-D printing in a recent tweet:

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And I heard from a friend that Dyson even has a healthcare “focus”.

Protecting Patients

There are some major concerns as these data-focused companies offer access but do so with agreements that contain so much legalese as to be unintelligible and opaque to the consumer who may well be giving up much more than his own personal data but potentially giving up his future health. The GINA act offers some protection to individuals who in sharing personal genomic data that tag them with a “pre-existing’ condition could have found themselves unable to access care. But the act did not go far enough failing to address the issue of other insurance and employers who can use this data to deny access or coverage and perhaps even employment?

We need the combined power of this patient data to create the insights into diseases but not at that personal expense. There are many technologies on the horizon that offer a potential path to help achieve this and blockchain represents an interesting innovation of decentralized secured data that offers individualized control and dynamic revocation options for access. If you are interested in learning more about Blockchain this article in HealthcareIt News is a good primer for its potential in Healthcare: How does blockchain actually work for healthcare?. It is not a panacea and the fundamental rights and ownership still need to be addressed without giving away the farm to corporations and businesses.

Interoperability

The existing healthcare system incentivizes behavior that is in opposition to a scalable nationwide vendor neutral interoperable patient-centered data. Our model has multiple groups who have a vested interest in the control and ownership of data (for example Payers, Providers, Patients and even employers). Each has their own economic and commercial drivers and in many instances, these do not coincide with open sharing of data. In a system that is driven by activity and delivering care (Fee for Service) sharing data could mean a reduction in work and income. Until our reimbursement system moves to a more holistic care model that focuses on wellness and outcomes and incentivizes behavior that delivers better health and outcomes for patients through cooperative and coordinated care and ultimately equitably rewards all the contributors to these outcomes we will remain stuck in the quagmire of limited interoperability.

The key to a patient-centered interconnected care model is the free flow of data between all the areas responsible for delivering care. We moved away from the single index card medical record held by your personal physician who was the focal point of care and care coordination to a distributed team-based model of care that encompasses multiple areas and people. In some instances, thatcher coordination may be carried out, at least in part by the patient or their family members, and they need to be included and ultimately in control of the data and its flow. The only way this team can deliver excellent care is through the frictionless flow of enhanced data and knowledge. This information flow must include the patient and all their family members that are authorized, interested and engaged in their care. Data should be shared with the patient’s consent with everyone concerned and available for as long as it is needed to deliver care but this access should be flexible enough to allow it to be revoked or removed when it is no longer needed or necessary

Welcome to the Fray

I am a big fan of learning from other industries and perspectives and spoke about this at HIMSS Conference in Orlando

The Best Exotic Marigold Hotel and I am excited to see the rush of companies and people into the healthcare space but for those stepping in and thinking about data and the ownership and control of this data, I would suggest this requires a new way of thinking. Much like security – patient access and control needs to be baked in from the start. Taking ownership and rights away from patients will stall progress and anger your constituents and community. As ePatient Dave would say or better yet sing:

Give me My Damn Data

Here’s hoping that these new players see the value of the engaged patient and include some of these principles in their march towards our common goal of better more cost effective healthcare. For the large organizations thinking about the data, remember you and your family members are patients too. The following thoughts are offered as some basic guiding principles on data stewardship:

  • Patients want control of their own data,
  • Patients want to be able to share safely and securely share their data with all their care providers and participants (this will include family members and friends)
  • Patients want granular control of some elements of the data limiting individual access to certain elements and areas
  • Patients requires a full audit capability tracking who has access and has accessed their data
  • Patients want to be able to easily and dynamically revoke access
  • Patients will share their data for research and benefit of others but their contributions need to be recognized and accounted for
  • Data cannot be used against Patients to deny coverage or increase their costs

 

What have I missed – what controls or limits would you place on your data that would make you more willing to share your data. What would stop you from sharing your data and why?

 

 

Patient Centered Systems was originally published on Dr Nick – The Incrementalist

Happy Birthday to my Best Friend

Posted in Inspiration, Kenya, life by drnic on April 19, 2017

 

I married my best friend and today is her birthday. This post: If You Want To Be Successful, Marry Your Best Friend detailed exactly why.

In this world of individualized culture that focuses on independence and self-reliance I am happy to say I am not. We are one and success and failure is our success and failure. We are programmed to have relationships and to belong — for those of you skeptical or feeling like you need independence you might just be suffering from the “dependency paradox”. I give up nothing and gain everything.

people who are more dependent on their partners for support actually experience more independence and autonomy, not less

This is what I would term “Healthy Dependency” and something that contrary to some viewpoints that see this as a negative quality in a relationship it is not but rather makes me a better person, stronger and more independent, successful and happier. I depend on her — we share the ups and downs of life and travel this journey called life together

Happiness is an experience best shared and I am lucky to be sharing this with my best friend and wife

Palazzo Vecchio with Uffizi in the Background

“The need for someone to share our lives with is part of our genetic makeup and has nothing to do with how much we love ourselves or how fulfilled we feel on our own. Once we choose someone special, powerful and often uncontrollable forces come into play. New patterns of behavior kick in regardless of how independent we are and despite our conscious wills.”

I love traveling this road with you and wish you a very Happy Birthday — We are One

Or the African version from this African boy

Happy Birthday to my Best Friend was originally published on Dr Nick – The Incrementalist

Wise Up to Hidden Healthcare Fees

It’s perverse but the healthcare system in the United States is making you sick. Don’t believe me – then maybe you have a high-end plan with no deductible and full access and no ceiling. But there are not many of those and for the rest of us, I imagine your interaction with the system is as frustrating and stressful as mine – probably on a spectrum depending on your plan (High deductible plan or the more traditional Preferred Provider Organization (PPO) and co-payments.

 

Fee for Service Healthcare

The cynical view might be this is deliberate since our system remains firmly stuck in a fee for service model – healthcare providers are paid to do something…anything. From its original development, this made sense – our capacity to treat conditions was limited and the cost of these treatments in line with our ability to pay for them. But along this journey science and in particular the incredible progress of medical research got involved and we have been on a veritable tear of progress and innovation, or as the Exponential Medicine group would say Exponential progress.

Original from Foundation Teaching Economics

There is a continued push towards a more robust and accountable model – Accountable Care Organizations have been set up and these models of total care and coverage and responsibility tested for effectiveness and economic effect. There is lots of disagreement on the success or failure of ACO’s and it is fair to say that the jury is still out. But intuitively we know that taking care of the complete picture and being responsible for the total care of patients health is better for the patient and for outcomes. I have seen it time and again where individual mandates or focus induce unwanted/unexpected/unintended consequences elsewhere in the whole system.

Discharging Patients Early – Unintended Consequences

Discharging patients from the hospital early typically results in better outcomes. Early programs that incentivized this behavior and rewarded programs that got patients out of the hospital early were deemed successful but failed to take account of the downstream impact of readmissions resulting from too early a discharge and subsequent complications for that patient that could have been avoided.

Fixing a Broken System

The recent book “American Sickness” by Dr Elisabeth Rosenthal “An American Sickness” takes on the existing system and is filled with strategies for patients faced with mounting medical bills, an intractable and aggressive healthcare system that is unflinching in seeking payment and by many estimates the leading cause of personal financial crisis and insolvency. While the figures remain under debate my own personal reality living with a High Deductible Plan that has found me

  • Self-treating Fractures
  • Becoming my own compounding pharmacy and
  • Spending months and many hours fighting multiple bills

 

In the case of one screening procedure, that under the current regulations are fully covered but thanks to either mistaken coding or perhaps even deliberate coding, remains outstanding and in two of the three cases, the billing organizations despite my attempts at regular communications, response and protests were handed over to debt collection agencies.

So I am with Dr. Rosenthal and “breaking down the monolithic business”.

The situation is far worse than we think, and it has become like that much more recently than we realize. Hospitals, which are managed by business executives, behave like predatory lenders, hounding patients and seizing their homes. Research charities are in bed with big pharmaceutical companies, which surreptitiously profit from the donations made by working people. Americans are dying from routine medical conditions when affordable and straightforward solutions exist.

Employer Sponsored Insurance

Central to the challenges is the arcane concept that you access to healthcare and health insurance should be linked to your employment. As one friend of mine commented, “There are some who believe this is a deliberate policy on the part of employers to lock in employees to jobs they may not want but have to take because they need the health insurance and can’t afford the challenge or cost of changing (health insurance”. I don’t quite go down that rabbit hole and think Dan Munro’s explanation in his great book “Casino Healthcare

that detailed the history linked to the war effort and the need to find other incentives after they introduced: “An Act to further the national defense and security by checking speculative and excessive price rises, price dislocations, and inflationary tendencies, and for other purposes.” (EPCA) in 1942 – wages were frozen to stop inflation but as is so often the case left the door open for unintended consequences that found employers looking for ways to compete for a shortage of labor. And as they say what follows is history – Employer Sponsored Insurance (ESI) was born.

History of the NHS

It is interesting to note that the NHS model was also a product of the war that found the wounded servicemen and women in need of healthcare. A need that was serviced by the “Emergency Hospital Service” (aka Emergency Medical Service) that provided a model and experience to the country that became the model for what is now the NHS established in 1946.

But whatever the history, reasons, and background – this remains a millstone around American’s. It can add to job reductions and General Motors have stated that their employee healthcare costs add $1,500 – 2,000 to the price of every car they produce. It makes us less competitive internationally and crippling many with overheads that add to the cost of goods sold. It also puts employers at the table on healthcare decision making for their employers that present potential conflicts of interest given their need to service their share holders and remain profitable.

Finding a pathway to resolving this big intractable healthcare mess is going to take some major re-thinking and compromise on all sides. In the meantime, I suggest focusing on individual incremental approaches locally.

 

Incremental Steps to Coping With Healthcare

The list of 6 Questions to ask your doctor before your appointment and 5 questions to ask before you stay in a hospital are excellent resources from Dr. Elisabeth Rosenthal, that are featured in the book and on the website. So in the spirit of the incremental approach, I offer up two credit card size templates containing the

  • 5 Questions to Ask During Your Hospital Stay
  • 6 Questions to Ask Before Every Doctor’s Appointment

 

Formatted in a handy Avery 5371 White Business Card Template that can be printed – double sided and put in your wallet: Questions When Using Healthcare Avery Template 5371

Do you have any tips or suggestions in dealing with the healthcare system? Disagree with any of this – feel free to leave your comments or reach out.

Wise Up to Hidden Healthcare Fees was originally published on Dr Nick – The Incrementalist

This 3DPrint Heart-on-a-Chip Could End A

Posted in Uncategorized by drnic on April 11, 2017

This 3DPrint Heart-on-a-Chip Could End Animal Testing #DigitalHealth http://ow.ly/zXpY30aI8xY

Incredible animation of Globe of World A

Posted in Uncategorized by drnic on April 10, 2017

Incredible animation of Globe of World Air Traffic over 1 year #travel http://ow.ly/OKLJ30aI8pJ

The Arctic Ocean Is Becoming More Like t

Posted in Uncategorized by drnic on April 10, 2017

The Arctic Ocean Is Becoming More Like the Atlantic Ocean #science http://ow.ly/E0CE30aI83f