2018 State of the Union: Healthcare Recap

What did you think of the State of the Union address?  I won’t get into all the policies and positions put forth by President Trump, but I will review his statements related to health care.

And we are serving our brave veterans, including giving our veterans choice in their healthcare decisions. Last year, the Congress passed, and I signed, the landmark VA Accountability Act. Since its passage, my Administration has already removed more than 1,500 VA employees who failed to give our veterans the care they deserve — and we are hiring talented people who love our vets as much as we do.
I will not stop until our veterans are properly taken care of, which has been my promise to them from the very beginning of this great journey.

The VA Accountability First Act of 2017 provides the government with “the authority to expeditiously remove, demote, or suspend any VA employee, including Senior Executive Service (SES) employees, for performance or misconduct”.  It would also increase rewards for whistleblowers and increase the financial penalties for employees due to misconduct, poor performance or even committing a penalty.

Was the law effective?  The Washington Post states that the 1,500 firings is  “inaccurate”. They write:  “It’s true that more than 1,500 firings at the VA have occurred so far during the Trump administration. But more than 500 of those firings occurred from Jan. 20, when Trump took office, to late June, when the new accountability law began to take effect. That means roughly one-third of the 1,500 firings cannot be attributed to the new law.

To speed access to breakthrough cures and affordable generic drugs, last year the FDA approved more new and generic drugs and medical devices than ever before in our history.

This is true. As NPR’s Alison Kodjak writes in their fact check: “The FDA approved 56 new drugs last year and 1,027 generics, a record in both categories.  FDA Commissioner Scott Gottlieb says the agency is on track to approve even more drugs this year.”  The focus on expedited review times is real.  However, the drug development process takes years or even decades, so clearly changes in government policies this year–while having the potential to change approval rates–will have little effect on current innovation, but could incentivize additional investments which would lead to future innovation.

We also believe that patients with terminal conditions should have access to experimental treatments that could potentially save their lives.   People who are terminally ill should not have to go from country to country to seek a cure — I want to give them a chance right here at home. It is time for the Congress to give these wonderful Americans the “right to try.”

As the Hill reports, “Last year, the Senate passed the bill, known as “right to try,” by unanimous consent, and groups backed by billionaire conservative donors Charles and David Koch are pushing the House to do the same. ”  Right now, the bill is before the House to come up for a vote.

Even if the legislation passes, this may not be as revolutionary change as some might believe.  As reported in STAT, “More than 30 states already have laws that allow some patients access to experimental treatments, and the FDA itself already has a pathway for granting expedited access to treatment to patients with terminal illness.”

These reforms will also support our response to the terrible crisis of opioid and drug addiction.  In 2016, we lost 64,000 Americans to drug overdoses: 174 deaths per day. Seven per hour. We must get much tougher on drug dealers and pushers if we are going to succeed in stopping this scourge.  My Administration is committed to fighting the drug epidemic and helping get treatment for those in need. The struggle will be long and difficult — but, as Americans always do, we will prevail.

The increase of opioid overdoses and deaths in the U.S. has been astounding over the past 20 years.  It is a problem that needs to be addressed.  Trump framed the issue of one of increased law enforcement rather than an issue to be addressed by the medical community.  Most experts argue that drug addiction is a demand-side problem, and improved treatment and support typically work better than additional law enforcement.

We eliminated an especially cruel tax that fell mostly on Americans making less than $50,000 a year — forcing them to pay tremendous penalties simply because they could not afford government-ordered health plans. We repealed the core of disastrous Obamacare — the individual mandate is now gone.

This is the repeal of the individual mandate.  Generally, the individual mandate was not popular; people don’t like being forced to do something.  Additionally, the cost of this insurance–even for many with subsidies was burdensome.

Without the individual mandate, however, healthy people generally leave the insurance pool driving up rates for those who are remaining.  There is a risk of an adverse selection death spiral, where rates would continue to rise.

The CBO estimates that repealing the individual mandate “would reduce federal deficits by about $338 billion over the 2018–2027 period and increase the number of uninsured people by 4 million in 2019 and 13 million in 2027.”

The point came as House and Senate Republicans mull passage of a bill to fund cost-sharing reduction payments and a reinsurance pool to try to stem premiums for unsubsidized enrollees in the exchanges next year.

One of my greatest priorities is to reduce the price of prescription drugs. In many other countries, these drugs cost far less than what we pay in the United States. That is why I have directed my Administration to make fixing the injustice of high drug prices one of our top priorities. Prices will come down.

This was one of President Trump’s campaign promises.  Vox notes that to date, however, bringing down prescription drug prices has not been a priority–although that of course could change.

However, it is not clear how exactly this promise would be implemented.  Would the government negotiate with pharmaceutical firms directly?  HuffPost is skeptical that this would occur  since “Republicans want nothing to do with that. (Plenty of Democrats don’t either, by the way.)”

There is general skepticism about the implementation.  As reported at AJMC,   “There’s certainly been a gap between rhetoric and reality,” said John Rother, president and CEO of the National Coalition on Health Care (NCHC).

One potential way to reduce costs is to facilitate generic drugs coming onto the market after patent expiration. New HHS Secretary Alex Azar seems to be in favor of this approach.

Pharmaceutical firms responded that despite the high sticker price, many drugs provide great value.  Eli Lilly CEO Dave Ricks disagreed with President Trump and said that prescription drugs, “they remain the best deal going in health care.”  PhRMA has a “Let’s Talk about Cost” campaign to bring some transparency to why prescription drug prices are so high.

Another question is what the President means by “prices”.  Are these the prices that health plans pay? Or is this the out-of-pocket cost that insured patients must bear?  Both have been increasing, but with the share of people insured through high-deductible plans rising (28% of those on employer plans as of 2017), patients are no longer insulated from changing drug prices.

2018 State of the Union: Healthcare Recap posted first on http://dentistfortworth.blogspot.com

What if Amazon ran hospitals?

Interesting thought experiment, especially in light of the recent Amazon+JP Morgan+Berkshire Hathaway collaboration.

 

The N.Y. Times states that:

Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Todd Combs, an investment officer at Berkshire Hathaway; and Beth Galetti, a senior vice president at Amazon.

 

What if Amazon ran hospitals? posted first on http://dentistfortworth.blogspot.com

Warren Buffett’s Healthcare Cost Tapeworm & His Alliance with Amazon and JPMorgan

The fact that the average U.S. employer committed to spend nearly $27,000 a year for a PPO to cover a family of 4 in America in 2017 is the most important rationale underlying the announcement that Amazon, Berkshire-Hathaway, and JP Morgan made on 30th January 2017.

That news immediately shook Wall Street trading, sending downward shocks down the proverbial spines of healthcare insurance plans and suppliers to the industry — legacy healthcare companies that scale patient-members and healthcare supplies, like pills and surgical implants.

The “new competition” chart published in the Wall Street Journal in the morning illustrates those shock waves…the word “disruption” comes to mind, although we won’t know how long-lived this kind of statistic will be. The companies illustrated are Express Scripts, the pharmacy benefit manager; CVS, the pharmacy which recently announced intentions to acquire Aetna, the health plan (also hit hard by the A-BH-JPM news), along with United HealthGroup, Cigna, and Anthem, the other major U.S. health insurers.

What has been long-lived, for the better part of two decades, is the upward climb of healthcare costs facing employers, who pay for 50% of healthcare in America. And, increasingly, employee-patients, who have become important payors in the process, as well, shouldering many thousands of dollars of that PPO cost in the form of shared premium, copayments, and coinsurance, according to Milliman, the actuaries, who calculated that $26,944 PPO cost figure.

The A-BH-JPM alliance isn’t about creating a new health plan, I’m sure. If you read this CNBC interview with Gary Cohn who closely works with President Trump, you would see he believes it’s akin to this White House’s push for association health plans as a Holy Grail to reduce healthcare costs. (Hint from this health economist — they won’t do that).

What the promise of the triple threat could bring would leverage the team’s data chops, enchanting consumer-centered design (#UX for you design wonks), trust (which bolsters consumer health engagement), and a collective passion for innovation.

Remember: when Aflac asked health consumers what they’d like their health insurance shopping experience to look like would be, 50% of folks said, “like Amazon.”

Health Populi’s Hot Points: I’ve analyzed the Milliman Medical Index for many years here on Health Populi, and use it in my advisory work. For each version, I identify stuff you could spend the PPO money on if not the health plan — usually I pick a car that’s priced at that PPO cost, and a second item such as a year at a university for a college student.

Ironically, last May, I picked 28 shares of Amazon stock, which at the time was worth roughly $27K.

Today, those 28 shares of Amazon stock would be valued at around $40,000. Amazon stock traded up over $8 today. Just think – one and one-half PPO plans…!

I will have more to say, over time, about this venture. For now, know that Warren Buffett has bitten that tapeworm that he’s long complained about, and based on my Twitter feed today, many of us are paying very close attention to the venture.

That includes many stock market investors whose holdings today got bit, hard.

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Warren Buffett’s Healthcare Cost Tapeworm & His Alliance with Amazon and JPMorgan posted first on http://dentistfortworth.blogspot.com

The 2018 Edelman Trust Barometer – What It Means for Health/Care in America

Trust in the United States has declined to its lowest level since the Edelman Trust Barometer has conducted its annual survey among U.S. adults. Welcome to America in Crisis, as Edelman brands Brand USA in 2018.

In the 2018 Edelman Trust Barometer, across the 28 nations polled, trust among the “informed public” in the U.S. “plunged,” as Edelman describes it, by 23 points to 45. The Trust Index in America is now #28 of 28 countries surveyed (that is, rock bottom), dropping below Russia and South Africa.

“The public’s confidence in the traditional structures of American leadership is now fully undermined and has been replaced with a strong sense of fear, uncertainty and disillusionment,” Edelman observes.

Government had the steepest decline (14 points) among the general population. Fewer than one in three believe that government officials are credible.

So who do we, the public, trust?

By industry sector, we trust technology, education, professional services, and transportation. We, the public, least-trust financial services, consumer packaged goods, and the automotive sector.

By country, the highest trust is for companies located in Canada (thank you, Prime Minister Trudeau), Switzerland, Sweden, and Australia. Least trusted nations for company HQs are Mexico, India, Brazil, and China. The U.S. is in the middle between most-and-least trusted, with 50% of the public trusting companies headquartered in America — a decline of 5 points since 2017, the largest fall of the countries surveyed.

By persona, who do we trust? Not our peers or people-like-us, as much as we used to. This year, we most trust technical and academic experts as the most credible spokespeople. “Credentialed sources are proving more important than ever,” Edelman found.

Health Populi’s Hot Points: In the U.S., “the biggest victim has been confidence in truth,” Edelman concludes. Richard Edelman, the company’s President and CEO, believes, “The root cause of this fall [in trust] is the lack of objective facts and rational discourse.”

Every year here on Health Populi, I assess the Edelman Trust Barometer’s health and health care implications. Back in 2012, the U.S. public trusted government much more, and social networks and people-like-me influenced our health and healthcare as a trusted source.

This chart on trust by industry sector illustrates that peoples’ trust in healthcare eroded by two percentage points over last year.

This year, health/care stakeholders have much to learn from the study. On the upside, it’s technical and academic experts who hold the most trust equity with consumers, even beyond peers (and collective social networks and platforms). Healthcare can leverage researchers (say, at pharma and life science companies), physicians and nurses (working in healthcare provider organizations), pharmacists (in retail pharmacies), and front-line nurse practitioners and clinical professionals in ambulatory care settings. At health plans, CEOs and leadership must bolster trust — and can — based on the Edelman Trust Barometer’s finding that 64% of the public believe CEOs should lead and not wait for government to mandate.

Technology is the most-trusted sector in 2018 — and healthcare has much to gain by modernizing the sector, going beyond the EHR implementations that have slowed down and physician productivity and burnt out their human capital and spirits based on the most recent Medscape physician survey.

Edelman has some recommendations for the biggest national “trust losers,” led by the United States, illustrated in the last chart. The five pillars are good advice for health/care:

• To guard information quality (based on evidence-based medicine and sound clinical research);
• To protect consumers (by reducing medical errors, harm, and healthcare disparities, right-sizing healthcare services, and shielding people from the financial toxicity of high healthcare costs);
• To safeguard privacy, ensuring consumers’ HIPAA rights in the U.S. for privacy and security, guarding against cyber-attacks on personal health information, and demonstrating the highest level of data stewardship on behalf of health citizens;
• To drive economic prosperity in communities, paying fair wages, supporting and respecting health care human capital; and,
• To innovate.

All stakeholders, public and private sector, “will need to work together to find a new foothold with the public, one that is firmly grounded in a commitment to truth.” Edelman advises overall. Certainly, this advice is well-crafted for health/care in America.

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COMPLETE Guide to Keeping Your Home Fresh

If you’re anything like us, we’ve been soaking in this last 2017-2018 winter season, weather and festivities included. So far, it’s felt like one cozy yet entertaining season.  

 

Of course, we all know what that means for the state of our homes: the house not getting as much fresh air as it needs, not as much day light—or light in general—plus so much post-holiday clutter that, in the end, you consider needed insulation.  

 

So, how do you tackle that growing to-do list without waiting until “spring cleaning” strikes two months from now? You take action without making excuses! Action, in our humble opinion, is usually facilitated by creating lists. And a timeline is the best way to organize a big task like spring cleaning into smaller goals.  

 

Here at Dr. Ku’s office, we think a calendar provides a wonderful structure for the small but meaningful tasks at hand. So we went ahead and broke down a 28-day How-To Guide by using the calendar of February! 

 

Let’s Begin:  

 

FEBRUARY 1 – Dust Ceiling Fans and Light Fixtures 

Start from the top of the room, as everything will fall to the floor and you will have to clean floors again if you dust ceiling fans out of order. Our quick and handy tip: use a pillowcase to wipe off all the dust on fan blades, then spray to clean up residual left. For most of us, there’s usually a LOT of dust! 

 

FEBRUARY 2 – Wash the Blinds 

Best bet is to wash these in the tub. If you don’t have that kind of time, use a vacuum with a soft bristle brush hose and then wipe them down with a Clorox wipe. 

 

FEBRUARY 3 – Clean the Curtains 

Depending on your budget and the quality of your curtains, you could either take them to the cleaners, have someone come to your house and steam clean them, or just throw them in the wash on a gentle cycle and immediately hang after washing.  

 

FEBRUARY 4 – Clean Windows 

This means inside and out. We know, we know…yes, it is probably going to rain right after you clean the outside of the windows (Murphy’s Law), but it must be done. 

 

FEBRUARY 5 – Clean Windowsills 

Yes, this also includes those little nooks and crannies that window frames come with. Use a cotton swab to clear out the gunk that a cloth or wipe doesn’t manage. 

 

FEBRUARY 6 – Clean Refrigerator/Freezer 

You’ll want to take everything out at appropriate times (no spoilage) and use something with as little chemical vapors as possible for scrubbing, like baking soda.  

 

FEBRUARY 7 – Clean the Outside of Appliances 

Just clean the outside of your appliances for now. Don’t put too much on your plate! This means cleaning the outside of the refrigerator, the oven, the microwave, the toaster, coffee pot, etc. And if you have a special cleaner for any appliances like those with stainless steel, be sure to use that.  

 

FEBRUARY 8 – Clean the Inside of Appliances, and the Kitchen Sink 

Dependent on how many appliances you have you’ll want to be sure to clean the inside of them. And we highly suggest not using the self-cleaning mode, as this can reduce the lifespan of the appliance. Hot tip: for the sink you’ll want to use the classic mixture of baking soda and vinegar to disinfect and rinse, that’s it!  

 

FEBRUARY 9 – Clean the Stovetop 

If you are one of the lucky folks with an electric glass top stovetop, then you most likely won’t have as much back-breaking work as those of us with a gas stove. Either way, be sure to remove all nobs and burners and clear away all debris, then sanitize with the appropriate cleaner.  

 

FEBRUARY 10 – Wash and Sanitize Doorknobs 

Did anybody get sick this winter? Have you even ever done this in your home? It’s scary to think there are people that don’t practice this. Sanitize all things you touch with your hands or use in shared spaces with others! That includes remote controls, phones, door knobs/handles/pulls, and even the door itself if pushed to open or close. 

 

FEBRUARY 11 – Wash Textiles 

After cozying up all winter in those comfy blankets and squishy pillows, you’ll want to get rid of any lingering smells by tossing them in the appropriate wash cycle. We’re talking sofa linens, bath and bedroom linens.  

 

FEBRUARY 12 – Clean the Dishwasher  

Yep, we said it. Even that machine that is supposed to clean things needs to be cleaned. Start by removing all racks and trays. Check the water-spinning holes to see if they’re clogged. Check the bottom of the door, the floor of the dishwasher, the drain, the gate and grill for debris that could be clogging up the process. Use a toothbrush with baking soda or warm soapy water, and set it on a rinse cycle when done. 

 

FEBRUARY 13 – Clean the Washing Machine 

Like the dishwasher, this machine also has to be cleaned…even though it is constantly cleaning! It still absorbs dirt, so wash this sucker down from top to bottom.  

 

FEBRUARY 14 – Dryer 

This one’s simple, and we sure hope you do it on the regular, but clear the lint trap from the dryer! This is a huge fire hazard. Every time a load is done drying, this should be cleared out. And be sure to keep the area around and behind the dryer tidy as well! 

 

FEBRUARY 15 – Sanitize Bathroom Fixtures 

You might have already accomplished this when wiping doorknobs and shared touched fixtures, but spend one day sanitizing bathroom fixtures specifically. We don’t need mention what particles could be flying in this vicinity…you get it. So keep every inch of it clean!  

 

FEBRUARY 16 – Bathroom Mats and Toys 

If you’re like some of us here in the office, you might have little kids or even grandkids. Surely, they have toys they like to play with in the tub. Grab those items, plus all the mats you and the kids use, and toss them in the washing machine with some vinegar. Keep they toys in a loose washer-safe baggy to avoid parts falling off.  

 

FEBRUARY 17 – Scrub the bathtub, shower, toilet and bathroom sink 

We’re talking about all that porcelain and ceramic. Grab your favorite cleaner, a two-sided sponge, some rubber gloves, and maybe even a toothbrush, and give these babies a good scrub down. We highly recommend using a bleach spray on any grout. Which leads us to our next task… 

 

FEBRUARY 18 – Cleaning the Grout 

Sprinkle baking soda on every bit of grout you find in your bathroom or kitchen, using a spray bottle filled with vinegar to apply over baking soda. Let it sit and bubble for a few minutes and then scrub—but not for too long, or the will settle back into the grout. 

 

FEBRUARY 19 – Wash Shower Curtains 

Your best bet might to be to just throw out the curtain and get a new one, but that will always depend. We recommend using an inexpensive curtain liner along with a fabric curtain that stays outside of the wash area. If it’s salvageable, washing with 1 cup of vinegar, your normal detergent and some old towels will do the trick. Hang to dry immediately after washing. As for the washing shower doors and getting that calcium depository to lift, we recommend a diluted mixture of vinegar, water, lemon juice and a baking soda paste. 

 

FEBRUARY 20 – Baseboards 

This is one of the chores we feel particularly passionate about! The baseboard actually has an architectural purpose: to catch the dirt that falls from the top of the room, down the wall and onto the floor. It’s also there to make it easier for you to clean, so let it see its purpose! Take a warm soap-wet cloth and run along the expanse of the baseboard, and then rinse the rag and wipe once more for any residual soap. Or, you can use a wet wipe. Your preference – just make sure to clean it! 

 

FEBRUARY 21 – Rugs and Carpet 

We know some rugs might be too massive to throw in the wash, but for the ones that are machine-washable at home, be sure to wash these regularly. When it comes to the larger rugs, try to prioritize having someone come clean them at your house, or renting a carpet cleaner from your local Home Depot or home improvement store. Rugs and carpets can be one of the biggest culprits of keeping your family sick, and the air in your home un-breathable.  

 

FEBRUARY 22 – Clean the Inside of Cabinets and Drawers 

This might actually be a task that takes a few days, but try tackling the cabinets and storage places that are messing with your daily grind the most. In places like the dish cupboards, just pull items out, wipe them down and put them back in place. Don’t take on too much by feeling the need to reorganize. The sheer act of wiping out may inspire you to mull over how better to organize the space at a later date.  

 

FEBRUARY 23 – 28 

We left a little wiggle room of 5 days because we know, just like us, you’re not perfect—and life happens. The hope is that you can accomplish at least one of these tasks a day, if not two (if you have the time)! And that by the end of the month your place will be feeling ready for a new season—it can be a clean spring instead of a spring of cleaning.  

 

Enjoy your February, and don’t forget between all this cleaning to schedule some down-time to cater to your personal care needs—one of those being your teeth! Making the time is how true self-improvement begins. Good luck, busy bee!

The post COMPLETE Guide to Keeping Your Home Fresh appeared first on Fort Worth Dentist | 7th Street District | H. Peter Ku, D.D.S. PA.

COMPLETE Guide to Keeping Your Home Fresh posted first on http://dentistfortworth.blogspot.com

In the U.S., Spend More, Get Less Health Care: the Latest HCCI Data

Picture this scenario: you, the consumer, take a dollar and spend it, and you get 90 cents back. In what industry is that happening?

Here’s the financial state of healthcare in America, explained in the 2016 Health Care Cost and Utilization Report from the Health Care Cost Institute (HCCI).

We live in an era of Amazon-Primed consumers, digital couponing, and expectations of free news in front of paywalls. We are all in search of value, even as the U.S. economy continues to recover on a macroeconomic basis. But that hasn’t yet translated to many peoples’ home economics.

In this personal economic landscape, patients across the United States who have health insurance through the workplace find themselves using less health care, and spending more. Why? It’s the prices.

This isn’t the first study to point out that, “It’s the Prices, Stupid,” when it comes to health care spending growth. That was coined way back in May 2003 by Uwe Reinhardt, Gerald Anderson, and colleagues in Health Affairs. 

But this round of HCCI’s annual reports is one of the first to call out the “spend more, get less” ROI for workers enrolled in employer-sponsored health plans. HCCI calculates that spending growing each year from 2012 to 2016 was almost all attributable to healthcare price increases – especially for emergency room visits, surgical hospital admissions, and administered drugs (that is, high cost specialty drugs). Use of health services declined or stayed flat in the period.

That last line-item, prescription drugs, is the green line on the top chart, growing by 27.2% — a faster growth rate than for outpatient care, professional services, and inpatient costs.

HCCI mined commercial health claims data from four insurers (Aetna, Humana, Kaiser Permanente, and United Healthcare), covering about 39 million U.S. workers under 65 years of age.

Health Populi’s Hot Points: Spending more, and getting less is my top-line finding from this report. Out-of-pocket (OOP) spending per covered employee increased between 2012 and 2016, but peoples’ utilization of health care services fell.

The increased adoption of high-deductible health plans among employers has shifted some of the health care financial risk to employees (which you can read more about here in Health Populi – on the financial risk-shift to consumers). Peoples’ self-rationing, or choice to use fewer health care services due to cost, is a rational short-term economic response to facing higher costs (prices) for health care. What that short-term choice might do to health outcomes in the longer-term is unknown: for example, disbanding or not filling a prescription for managing a chronic condition, or avoiding seeking medical care when one feels unwell…or a mysterious lump somewhere on their body.

Deferred Care – How Tax Refunds Enable Healthcare Spending is a report released earlier this month in which the President and CEO of the JPMorgan Chase Institute said, “The reality is that many American families don’t have the cash buffer to withstand the volatility created by out-of-pocket healthcare payments, and we need to better understand the correlation between financial health and physical health.”

The second (blue) chart, from the report, shows that a patient’s personal cash-flow is a driver of out-of-pocket healthcare spending — in this case, the cash infusion of a tax refund, triggering OOP spending: consumers immediately increased their OOP spending by 60% in the week they received a tax refund, and then 20% more over the 75 days following the tax refund.

The third (orange) chart shows that the tax refund motivated consumers to visit healthcare providers (doctors and dentists) and pay outstanding hospital bills which were deferred.

Another key finding in this research is that consumers timed major medical payments to occur in months when their income and liquid assets increased.

The bottom-line here is that physical health and fiscal health are bundled for U.S. patients. JPMorgan Chase recommends that insurers, employers, providers, and financial services companies, “ensure consumers receive healthcare when they need it, rather than just when they have cash on hand to pay for it.”

Only in America.

 

 

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In the U.S., Spend More, Get Less Health Care: the Latest HCCI Data posted first on http://dentistfortworth.blogspot.com

Healthcare EveryWhere: Philips and American Well Streamline Telehealth

Two mature companies in their respective healthcare spaces came together earlier this month to extend healthcare services where patients live and doctors work, via telehealth services.

Philips, celebrating 127 years in business this year, has gone all-in on digital health across the continuum of care, from prevention and healthy living to the ICU and hospital emergency department. American Well is among the longest operating telehealth companies, founded in 2006. Together, these two established organizations will transcend physician offices and ERs and deliver virtual care in and beyond the U.S.

I had the opportunity to sit down with Ido Schoenberg, MD, Chairman and CEO of American Well, and Jeroen Tas, Chief Innovation & Strategy Officer at Philips, at CES 2018 where they made this announcement.

In Philips’ broadening digital health portfolio, the company has developed connected products to address a number of health and wellness life-flows for people in their homes. These deal with the age range from baby through adult, and can cover head-to-toe. For example, Philips has products addressing cardiac/heart care, respiratory and sleep care, skin care, and oral care, along with connected thermometers, blood pressure devices, and weight scales.

The first use case for which the two companies will collaborate will leverage Philips’ uGrow parenting app which manages “connected baby” things: monitors, thermometers, feeding bottles, among them. Each of these are part of the growing Internet of Baby Things. Each of them generates data managed through the uGrow app,

Now imagine you as a parent are awoken by your baby in her room, who is woefully crying and registers a temperature of 105 degrees on her connected thermometer. The Philips/American Well alliance is designed to come to your parental rescue, and your baby’s: the app will enable on-demand real-time video consults between you and a medical professional – a pediatrician, GP, mental health professional – potentially replacing an inconvenient, and expensive, ER visit in the middle of the night.

That’s a very helpful scenario from a parent’s point-of-view (been there, done that – not the pediatric telehealth part, but the high-fever baby? Absolutely, and frightening).

But what about payment? asked the health economist (me). Schoenberg explained that American Well has been working with payors for years: the company has invested significantly in building a platform that manages patients’ health plan information so that her co-pay or coinsurance amount can be quickly identified, streamlining and bringing transparency to the transaction.

Again, consider the ER scenario: inconvenient, to be sure. Expensive? You bet.

This pediatric use case illustrates that together, the companies bring an easy on-ramp to clinical care, virtually, for concerned parents.

The data play here is also important: “If you can build a longitudinal view of the patient (say, a growing baby into childhood), you can be at the right place and right time to intervene before anything deteriorates,” Tas observed.

“This is a powerful value proposition,” Tas noted. “We have a healthcare system where capacity is not efficiently allocated, locked in brick and mortar. We can help balance supply and demand,” which were lovely words to this health economist’s ears.

Schoenberg noted that American Well is connected with over 100 hospitals (from “A” AllianceHealth Oklahoma to “W” for University of Wisconsin), health plans (including Anthem, who sits on the AmWell Board, many Blue Cross & Blue Shield plans, Optum and UnitedHealth Group), employers (such as Pitney-Bowes, one of the savviest companies pioneering value-based healthcare), and partners like Cerner (linking into the company’s EHR), CVS, Samsung, and Walgreens.

While consumers, especially younger ones (THINK: first-time parents), are increasingly demanding more accessible, convenient, lower-cost channels for health care, providers are also organizing to adopt telehealth. Vidyo’s survey, released this week, found that 3 in 4 U.S. healthcare delivery systems plan to launch a telehealth service in the next year. The company believes 2018 will be the year that telehealth morphs into mainstream healthcare delivery.

Key drivers for telehealth adoption among providers include efficiency, timeliness of care, ROI, and patient health outcomes. Satisfaction scores are relatively high for telehealth solutions, reaching 83% for virtual visits, 84% for acute care, and 90% for chronic health support, Vidyo learned.

The Philips/American Well alliance is well-positioned to address this growing demand, especially bringing the patient-financial aspect into the process.

Health Populi’s Hot Points:  Seven in 10 health systems not currently receiving reimbursement for virtual care expect to receive payment in 2018, according to the Top of Mind for Top U.S. Health Systems 2018 report from UPMC Center for Connected Medicine and The Health Management Academy. Reimbursement has long been a barrier to many healthcare providers avoiding telehealth, but as payment aligns for the service, we can expect hockey-stick growth.

The chart indicates some of the most popular clinical areas for virtual care, especially stroke, mental health, primary care, along with emergent and urgent care. Note that three-quarters of respondents believe that virtual care would improve quality and safety for patients. Four in ten providers are motivated by demand from patients, and nearly one-half see virtual care as a cost-containing effort.

Sean Duffy (Co-Founder and CEO of Omada Health) and Thomas Lee, MD (Chief Medical Officer at Press-Ganey), published a provocative perspective in New England Journal of Medicine on 11 January 2018 titled, In-Person Health Care as Option B. They ask the question: “What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first?”

They explain how Kaiser Permanente now conducts over one-half of their patient encounters virtually, through secure email and video engagement. Not only is Kaiser a major provider of virtual care: Providence-St. Joseph Health’s Express Care system is now deployed in 33 clinics in four states. Interestingly, Providence-St. Joe’s operates a service called The Circle targeting expectant moms (thus, taking a page out of the Philips and American Well virtual care playbook.

Duffy and Lee conclude their essay with a statement that might sound counter-intuitive: “clinicians and systems that lean in toward this change rather than resist it may find that it deepens their partnerships with patients. Patients who find their needs being addressed simply, quickly, and efficiently will know that if the system requires and in-person visit, it’s doing so because of necessity.”

The authors know that patients, humans, are evolving as Homo informaticus: multi-channel, multi-screen and –platform consumers many of whom are also “Amazon-primed” for service and immediate (or near-immediate) gratification. Trust is bolstered through respect, and Duffy and Lee are spot-on about the role that virtual care can play to build stronger clinician-patient relationships.

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To get our money’s worth in healthcare, we need to collaborate

This is the title of an interesting commentary in Modern Healthcare by my colleague Mark Linthicum. An excerpt is below.

In healthcare, different stakeholders have vastly different perceptions of value, with important implications for decisionmaking. An employer paying for healthcare may want to find solutions that decrease employee absences and prevent lengthy hospitalizations. A health insurer might prioritize reducing total costs in the short run, especially if it has frequent enrollee turnover. An insured patient—especially one of the increasing number of patients on high-deductible health plans—would likely care much more about out-of-pocket costs and impacts on their quality of life. The list goes on.

Every healthcare decision affects multiple stakeholders—most importantly, patients—but current value assessments tend to be conducted from a single perspective. There is currently no consensus on a scientifically credible and unbiased way to measure value in treatments and services. To make matters worse, current assessments of value often lack transparency, which makes it difficult to gauge accuracy or engage in constructive dialogue.

The Innovation and Value Initiative is working to change that.

In November 2017, the IVI launched the Open-Source Value Project to provide an objective, scientifically credible and truly collaborative way for all healthcare stakeholders to individually measure value in treatments and services. We’ve kicked off the project with a tool measuring value in treatments for rheumatoid arthritis, one of our nation’s costliest chronic diseases. As its name indicates, the Open-Source Value Project uses an open-source modeling approach to measure treatment value. Like open-source software, all of our tools and models are freely available for use by everyone and are continually evolving based on user feedback.

The article provides more detail on the challenges facing value frameworks, and how more open, flexible approaches to measuring value–such as those developed at the Innovation and Value Initiative–can help bridge the divide across stakeholder groups.

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Then and Now—The History of Fort Worth

Once upon a time, Fort Worth’s population a mere 500 people, when the sidewalks were made of wood trestles. 500 people could be found sitting along a river, setting up camp…setting up a way of life that–till this day–Fort Worth continues to embody and represent: an entrepreneurial, hard-working society of like-minded people.  

 

Here at Dr. Ku’s office we are proud to call Fort Worth our home, and want to help paint the picture of Fort Worth’s history to the people who continue to trust in our care. So, let’s begin with the timeline! 

 

1843: Treaty of Bird’s Fort was signed between the Republic of Texas and several Native American tribes that declared no one may pass or reside over “the line of trading houses,” or the Indian’s territory, without permission of the President of Texas.  

 

1849: The original “trading houses” were later established by the U.S. Army and War Department to protect the changing American Frontier after the Mexican-American War. In January 1849, U.S. Army General William Jenkins Worth (a veteran of the Mexican-American War) proposed to build more forts to mark and protect the west Texas frontier, but sadly passed away five months later. His initiative, however, lived on. In June of 1849, Camp Worth was established in honor of General Worth at a north-facing bluff that overlooked the mouth of the Clear Fork.  

 

1854: John Peter Smith opened a school to twelve students, and residents Archibald Leonard and Henry Daggett started the town’s first department stores.  

 

1856: Julian Field opened a flour mill and general store. The Butterfield Overland Mail and the Southern Pacific Stage Line used the town as their western terminal en route to California. 

 

1860: Construction on the controversial (and rightful location) of the county courthouse began, although it was not finished until the 1870s due to the Civil War.  

 

1870: Captain Martin B. Lloyd opened an “exchange” office that later evolved into the First National Bank, chartered in 1877.  

 

1872: Three more residents opened new general stores in town.  

 

1873: With a population of 500, Fort Worth became incorporated by holding an election for a mayor-council government; Fort Worth National Bank was established at this time, too. However, a severe winter dealt a harsh blow to the once-bustling cattle industry, and so railroad construction halted, leaving many out of a job and onto the next city with greater opportunity.  

 

After an article was published that someone had seen a panther asleep in the street outside the courthouse, the nickname “Panther City” stuck as Fort Worthians embraced the jest while they recovered in the next few years from the depression.  

 

1876: The Texas and Pacific Railway came to Fort Worth, causing a boom in the stockyards to become a premier city for the wholesale trade of cattle. As the industry grew, people from the war-torn south flooded in to Fort Worth for work. In the years that followed, oil and aviation brought new wealth to the region, turning a once small camp into a bustling city. 

 

1881: The first telephone exchange began operating in 1881, with 40 customers. Fort Worth saw a booming population of approximately 7,000 people. 

 

1885: Electricity came to the city. 

 

1889: The original Texas Spring Palace was erected. Sadly, it burnt down only a few months later. Later the citizens raised money for a monument of the civil engineer Al Hayne, who saved many lives in the fire—the monument still stands today.  

 

1900: Population reported at 26,668.  

 

1902: Packing houses Swift & Company, Armour & Company an McNiel & Libby all came to Fort Worth due to the bustling cattle industry, establishing Fort Worth as the epicenter of packing houses in the southwest.  

 

1909: The Fort Worth Gas Company was organized and began serving 3,840 customers with their 90-mile pipeline from Petrolia, Texas. Fort Worth Zoo, the oldest continuous zoo site in Texas, was opened. 

 

1914: World War I broke out, giving Fort Worth a run for it’s money with oil and war needs. 

 

1917: Due to the mild climate permitting year-round training, Camp Bowie was established by the U.S. Army where 100,000 men were trained, as well as where aviation activity training centers were established. 

 

1920: Oil stock exchanges were established in Forth Worth when refinery and pipeline companies such as Sinclair Refining Company, Texaco, and Humble Oil and Refining Company began their operations in the city. 

 

1914 – 1945: Due to the needs of the wars Fort Worth became a metropolis between the years of both World Wars. Many of the city’s most prominent architecture and businesses were established that still exist today. The Fort Worth Army Field, a Quartermaster Depot and Marine Air Base, was constructed in Fort Worth—signifying a milestone in the city’s ability to employ and safeguard its country with aviation. 

 

1948 – 1951: The Army Airfield was renamed Carswell Air Force Base, and to this day connects Fort Worth to its military heritage and prosperity.  

 

1980s: Major city revitalization started with the introduction of Sundance Square, new office towers, hotels popping up and the convention center being remodeled, making Fort Worth a 35-block commercial, residential, entertainment and retail district. 

 

Present Day: Once just a cow town, Fort Worth continues to embody it’s past by remaining one of the fastest growing cities in the nation, and represents a proud Western heritage not being forgotten any time soon. 

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Medicaid and paperwork

When you buy a typical product, the vendor does its best to make the purchasing process as easy as possible.  There is a reason for this, clearly; they want your business.  State and federal governments, however, have no such incentive.  In fact, oftentimes reducing the number of people using government services saves money.

Thus, it should come as no surprise that the government uses paperwork as a barrier to access health insurance.  The New York Times reports:

In 2003, Washington State was facing a budget crisis and wanted to reduce spending on Medicaid. Instead of requiring people to establish their eligibility annually, the legislature began requiring them to do so twice a year, and added some paperwork. It worked: Enrollment in the health insurance program fell by more than 40,000 children in a year.

A recent decision by President Trump could exacerbate access to health insurance among poor individuals.

The Trump administration’s decision to approve a first-of-its-kind work requirement for Kentucky’s Medicaid program last week has inspired concern that the program will leave behind Medicaid beneficiaries who are unable to find or keep work. But a large body of social science suggests that the mere requirement of documenting work hours is likely to cause many eligible people to lose coverage, too.

“Without being tremendously well organized, it can be easy to fail,” said Donald Moynihan, a professor of public affairs at the University of Wisconsin-Madison, who is writing a book on the effects of administrative burdens.

Clearly providing health insurance is costly.  States that want to cut costs could either (i) reduce eligibility, (ii) make it more difficult to access insurance through paperwork, (iii) reduce benefits among the insured, or (iv) reduce reimbursement for providers of the benefits.  Options (i) and (ii) are functionally similar as both reduce coverage. However, option (ii) is less efficient due to the wasted effort on paperwork; however, (ii) could be more efficient if only people who highly value insurance go through the trouble of doing the paperwork.  Option (iii) does not decrease the number covered, but provides lower quality coverage for these people.  Option (iv) also does not decrease coverage but lowers the quality of insurance provided; as fewer doctors accept the lower reimbursement, accessing care becomes more difficult and thus, de facto, quality of care falls.

What level of public funding on health insurance is a continual debate.  But if lower spending is decided, tough choices that involved fewer people receiving care or people receiving lower quality care (or a combination of the two) would be required.

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This month’s Health Wonk Review

Joe Paduda gets the year started with his  fresh edition of Health Wonk Review: Ring in the New year with the latest and greatest…posted at Managed Care Matters.  Check it out!

 

This month’s Health Wonk Review posted first on http://dentistfortworth.blogspot.com

Hug Your Physician: S/He Needs It – Listening to the 2018 Medscape National Physician Burnout & Depression Report

Two in five U.S. physicians feels burned out, according to the Medscape National Physician Burnout & Depression Report for 2018.

This year, Medscape explicitly adds the condition of “depression” to is important study, and its title. In 2017, the Medscape report was about bias and burnout.

Physicians involved in primary care specialties and critical care are especially at-risk for burnout, the study found. One in five OBGYNs experience both burnout and depression. Furthermore, there’s a big gender disparity when it comes to feeling burned out: nearly one-half of female physicians feel burnout compared with 38% of male doctors.

Being employed by a health system or self-employed doesn’t appear to make a difference in burnout: equally, 42% of physicians feel burned out whether self- or system-employed.

Above all factors, it’s the job that burns physicians out, as opposed to finances, family, love life, or personal health.

Burnout and depression impacts how physicians deal with both colleagues and staff as well as patients. One-third of physicians who are depressed say patients “exasperate” them.

What contributes to physician burnout? the survey asked.

It’s onerous bureaucratic tasks — think EHR implementations, paperwork, insurance company hassles, and time away from hands-on patient care — feeling like one is working at their highest-and-best use.

“Exercise” is the most popular self-care tactic used by one-half of physicians to deal with burnout and depression.

In the meantime, note that only 9% of male doctors and 13% of female clinicians are currently seeking help to deal with their burnout/depression, Medscape found.

Health Populi’s Hot Points: Of all the surveys in healthcare we could learn from in 2018, this will be one of the most important.

Many of us working in healthcare have added a fourth leg to the Triple Aim stool: in 2018, we must attend to the Quadruple Aim, which calls out the challenge of clinician burnout as a key factor in helping make healthcare better.

In 2014, Dr. Thomas Bodenheim and Dr. Christine Sinsky talked about the Quadruple Aim in this seminal discussion in the Annals of Family Medicine. They wrote about, “care team well-being as a pre-requisite for the Triple Aim.”

Furthermore, Bodenheim and Sinsky noted that, “The barriers to achieving the Triple Aim include improving population health in a society experiencing obesity and diabetes epidemics and growing income disparities, rising health care costs, and a dispirited and disengaged health care workforce…Health care is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, benefiting both parties.”

Ultimately, what benefits physicians and nurses benefits patients: we are in a shared health commons. Any healthcare reforms that diminish the importance of either clinician or patient in health care work- and life-flow will do further harm to an already-fragile healthcare system.

 

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What is evidence-based health policy?

Many people have heard of evidence-based medicine (EBM).  A perspective piece in the New England Journal of Medicine by Katherine Baicker and Amitabh Chandra, however, tries to define what evidence-based health policy (EBHP) is.  They list three key criteria:

• Policies need to be well-specified.  For instance, “expand Medicaid coverage” is too general, whereas specifying that benefit package A be extended to population B at cost C, is getting to more of the specifics needed.
• EBHP represent policies, not goals.  The same exact value-based purchasing program, for instance, could have multiple goals, (e.g., reducing cost, improving quality).  The policy itself is what is being evaluated, whereas the goals depend on the evaluator’s perspective.
•  EBHP requires evidence of the magnitude of the effects of the policy.  Empirical evidence is needed to show a specific health policy works.  Further, just showing a statistically significant result is not enough, it also must be of sufficient magnitude to be relevant to stakeholders, especially when compared against other policy interventions.

In addition, the authors argue that the perfect should not be the enemy of the good. That is my interpretation of the authors saying that “In health policy — as in any other realm — it is often necessary to act on the basis of the best evidence on hand, even when that evidence is not strong. Doing so requires weighing the costs of acting when you shouldn’t against those of not acting when you should — again, a matter of policy priorities.”

Conducting health policy research is complex not only due to the empirical complications, but also because policy goals and priorities vary across stakeholders and empirical evidence of the effect of health policies may or may not resolve this debate.  Nevertheless, by using evidence-based approaches to identify the effect of health policies, society can make these policies decisions knowing full well the implications of their decisions.

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What Healthcare Can Learn from A Pig and Piggy Bank via Santander Bank

When patients feel disrespected in a medical exam room, they will be less likely to follow instructions they receive from a doctor. Research from the Altarum Institute revealed this fundamental finding.

The chart shows that feeling respected reduces  a patient’s diabetes medication adherence by a factor of nearly 2x, and is a risk factor for poorly managed diabetes.

Furthermore, consumers who feel disrespected by providers are three times more likely to not believe doctors are accurate sources of information than consumers who do feel respected. And, patients with diabetes who do not feel respected are one-third more likely
to have poorly controlled diabetes than patients who feel respected by providers.

Exactly one year ago, Altarum published this research, sponsored by Robert Wood Johnson Foundation and Oliver Wyman, in a report called, Right Place, Right Time.

“Consumers believe online booking, easy comparisons of procedures and facilities, and plain language explanations would be especially useful improvements to their health care experiences,” Altarum summarized.

Now, watch this ad from Santander Bank.

Health Populi’s Hot Points: I had the opportunity to moderate a panel at last week’s Digital Health Summit during the CES 2018 in Las Vegas. My panel of participants included Marc Leibowitz from Johnson & Johnson, Dr. Lewis Levy of Teladoc/Best Doctors, and Rob Le Bras-Brown of Nokia. We brainstormed “Power to the People” in health care: the state of and conditions for consumer empowerment in health care. All the shiny new digital health things in the growing world of connected health-tech won’t move the needle on public, population, or individual health (or costs) if patients – consumers, caregivers, all — don’t feel engaged or activated with their health care.

While we covered the landscape of digital health technology, I noted before the end of the panel the statistics from the Altarum study: that trust and respect are precursors for health engagement. No wonder so many consumers look to friends and family before doctors, pharma, and researchers for health information and peer-to-peer support. As health care migrates to more virtual forms via telehealth and internet connections, clinicians’ “webside manner,” health plan personalization, and other user-facing experiences will become even more important.

The Santander message speaks to our humanity, empathy, and financial wellness — all components of the Holy Grail of health engagement.

It helps, of course, that Piggy is so darned cute.

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Longitudinal Modelling of Healthcare Expenditures: Challenges and Solutions

Previous analyses–such as Basu and Manning 2009–have addressed the problem of mass of health care expenditures around $0. In typical economic analyses, we assume that the dependent variable is normally distributed. In the case of health care expenditures, however, a large number of people have $0 expenditures (i.e., healthy individuals). Further, among sick individuals that incur positive health care expenditures, the expenditure distribution is typically heavily right-skewed. Approaches such as a two-part model have been used to address this type of health care spending distribution for cross-sectional data.

When addressing these distributional challenges for cross-sectional data, however, there are additional challenges. As Smith et al. 2018 write

There are additional considerations with longitudinal expenditures, and less research compares strategies for modeling longitudinal expenditures. As with any longitudinal outcome,
the estimation must incorporate the correlation of repeated measurements (Basu and Manning 2009). Furthermore, the distribution of longitudinal expenditures and the proportion of zeros are dependent upon the timeframe under consideration (e.g., person-month vs. person-year).

Using 2000-2003 VA data for veterans with hypertension, they authors test the model fit of four models:

• One-part models. “A one-part generalized linear model (GLM) fit the data using generalized estimating equations (GEEs) and treats the observed expenditures as realizations of a single process, so the model does not distinguish between zero and positive-valued expenditures.  The estimating equation is g(E(Y_ij)=βX.  Often the function g() is the log function.  “Similarly to GLMs fit with quasi-likelihood for cross-sectional expenditures, GLMs fit via GEEs do not require specification of a parametric distribution…Rather, one specifies only the mean and variance. Often, the variance is given as a mean–variance relationship (e.g., variance proportional to the mean, Var[E(Y_ij)]=ρ E(Y_ij), where ρ represents a proportionality constant), and a link function, as described above, provides the form of the mean model.” One can implement these regressions using standard software (e.g., SAS’s PROC GENMOD using a REPEATED statement and PROC GEE ; for Stata use xtgee and with R’s gee or geepack work
• Uncorrelated two-part models.  These models are useful when there are a large number of 0’s or if researchers are interested in the process through which patients occur $0 of expenditures. Two-part models have a binary component–often logit–measuring the likelihood of having $0 expenditures, and continuous part modeling the expenditure distribution conditional on positive costs. One complication, however, is that the first part of the model measures the P(Y_ij=0) for all individuals whereas the continuous part measures spending only among individuals with positive expenditures.  One other challenges is that these two model components “…are often correlated over time, such that the probability of incurring any expense is associated with level of expenditures over time. Failure to account for this correlation leads to informative cluster sizes in the second component and biased results.

• Correlated conditional two-part (CTP) models. “The correlated conditional two-part (CTP) random-effects model allows for estimation of correlation between the binary and continuous parts of the longitudinal expenditures by specifying a joint random-effects distribution, including correlations/covariance between the random effects. One can model these as shown below. The two-part models are the same as below, but omit the random intercepts, b_1i and b_2i, which are assumed to be distributed multivariate normal. Although this model can be implemented with some standard statistical packages (e.g., PROC NLMIXED in SAS) it is much more complex than the two options above.
  • logit(Pr(Y_ij>0)=αX+b_1i
  • E(log(Y_ij|Y_ij>0)=δX+b_2i
• Correlated marginalized two-part (MTP) models.  These models are similar to the CTP, but the continuous, second part of the model is not continuous as shown in the example below. Like the CTP, this is computational difficult to implement, although it has been done with Bayesian approaches. “Similar to the correlated CTP model, parameter estimates in the binary component are subject-specific estimates. Specifically, exp(αk) represents the subject-specific odds ratio for incurring positive expenditures associated with a one-unit increase in the kth covariate. Parameter estimates in the second component represent effects on the overall mean, and those corresponding to covariates not included as random effects are both subject-specific and population average.”
  • logit(Pr(Y_ij>0)=αX+b_1i
  • E(log(Y_ij)=δX+b_2i

You can read the paper to see the results of the authors application to the VA data.  However, the authors do provide some useful guidance in the discussion section regarding model selection.

First, is there interest in what influences the probability of incurring expenditures? If so, a two-part model may be appropriate. Secondly, is the primary interest in overall mean expenditures of the entire population or is more interest in the level of expenditures conditional on them being incurred? If the former, the one-part GLM or the MTP model is preferable; if the latter, one should consider a CTP model. The uncorrelated two-part GLM should only be considered if the analyst feels confident of no correlation between the two components, often an untenable assumption.

• Smith, Valerie A., Matthew L. Maciejewski, and Maren K. Olsen. “Modeling Semicontinuous Longitudinal Expenditures: A Practical Guide.” Health services research (2018).
• Basu, Anirban, and Willard G. Manning. “Issues for the next generation of health care cost analyses.” Medical care 47, no. 7_Supplement_1 (2009): S109-S114.

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The gold standard of scientific evidence

That is the title of my latest article in Pharmaceutical Market Europe. An excerpt is below.

Randomised controlled trials (RCTs) are regarded as the gold standard of scientific evidence,
and for good reason. By randomizsing a treatment across study arms, RCTs eliminate patient-treamtent selection bias, resulting in reliable causal inference. In contrast, in the real world patients woh are sicker may be more (or less) likely ot receive certain treatments. Because treatments are given selectively, the true causal effect of a treatment on patient health in most real-world studies cannot be determined…Nevertheless, in recent years, there has been a call to increase the use of real-world evidence (RWE)…

The rest of the article discusses some of the limitations of RCTs and places where RWE can be used to help improve health care decision-making. Do read the whole article.

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Calling Out Health Disparities on Martin Luther King Day 2018

On this day appreciating the legacy of Martin Luther King, Jr., I post a photo of him in my hometown of Detroit in 1963, giving a preliminary version of the “I Have a Dream” speech he would deliver two months later in Washington, DC.

Wisdom from the speech: “But now more than ever before, America is forced to grapple with this problem, for the shape of the world today does not afford us the luxury of an anemic democracy. The price that this nation must pay for the continued oppression and exploitation of the Negro or any other minority group is the price of its own destruction. For the hour is late. The clock of destiny is tickling out, and we must act now before it is too late.”

As I meditate on MLK, I think about health equity. By now, most clued-in  Americans know the score on the nation’s collective health status compared to other developed countries: suffice it to say, We’re Still Not #1 for health outcome, albeit we’re the biggest spender on healthcare, per health citizen, in the world.

Underneath that statistic is a shameful state of health affairs: that people of color in the U.S. have lower quality of health than white people do:

• Black women have higher breast cancer death rates than White women
• Asian women are less likely than White women to receive a pap smear
• Hispanic women are more likely than non-Hispanic White women to be diagnosed with cervical cancer at an advanced stage
• Rates of hospital admissions for uncontrolled diabetes are higher for Black women than for women in other racial/ethnic groups
• The rate of hospital admissions for lower extremity amputations due to uncontrolled diabetes is higher for Black women than White women
• The rate of new AIDS cases is higher for Black and Hispanic women than for non-Hispanic White women. Black and Hispanic men had even higher rates than women, as well as higher rates than non-Hispanic White men
• Black women receive treatment for depression less frequently than White women and Hispanic women received treatment less frequently than non-Hispanic White women
• Hispanic women received treatment for substance abuse less frequently than non-Hispanic White women.

If these statistics don’t move you, then here’s a finding from the National Academy of Science’s Shorter Lives, Poorer Health that might surprise you: today, people in the U.S. under 50 have poorer health outcomes than our cohorts in other developed countries. For women under 50, we’d rather live in other industrialized countries where fewer women under 50 die from noncommunicable diseases, heart disease, injuries, perinatal conditions, drug-related causes, and communicable and nutritional conditions.

Yes, more younger women in the U.S. — the wealthiest nation in the world — lose more life-years due to malnutrition, infectious disease, injury, and lifestyle-borne diseases like diabetes and heart disease than in our fellow rich countries.

What’s new today versus previous MLK Days is that the rate of white male middle-age deaths is on the rise, as well. So when we consider health disparities and public health, it’s important to realize there’s one boat, one health commons, and every person in America is impacted by those social determinants of health beyond the healthcare system: clean air (ask a miner in West Virginia), clean water (as your cousin in Flint, Michigan), good jobs (with health benefits – ask any worker without them), nutritious food (ask someone living in a food desert(, social connections (ask an isolated senior), and in my growing appreciation, access to connectivity/broadband networks (ask anyone looking for a job without a good smartphone data plan).

Read what U.S. doctors have to say about health disparities in JAMA. Top line for doctors lies in the concluding sentence: “Apart from the human and economic consequences affecting today’s adults and workforce, the health disadvantages faced by today’s children carry profound implications for tomorrow’s adults, the nation’s economy, and national security. Now the question is what US society is prepared to do about it.”

There’s another paragraph from MLK’s speech he gave at the Great March of Detroit that especially resonates today:

“We are coming to see now, the psychiatrists are saying to us, that many of the strange things that happen in the subconscious, many of the inner conflicts, are rooted in hate. And so they are saying, “Love or perish.” But Jesus told us this a long time ago. And I can still hear that voice crying through the vista of time, saying, ‘Love your enemies, bless them that curse you, pray for them that despitefully use you.'”

Health Populi’s Hot Points:  I am a child of metro Detroit. As a very little girl, I lived through the Detroit Riots of 1967, the day after which my father drove us through the fire-devastated neighborhoods of his friends and clients who lived and worked around 12th Street and Grand River.  It was a visceral moment for me in my life, one of my earliest memories, seeing burned-out shops on pedestrian main streets. I remember still the smoky smell which imbued my young lungs. I wondered why something like this happens.

In a few years’ time, I was reading Martin Luther King’s book, Why We Can’t Wait; The Autobiography of Malcolm X, and Native Son by Richard Wright — still, one of my favorite books. In college, I delved deeply into urban economics and urban planning, soaking in Jane Jacobs book, The Death and Life of Great American Cities, among other influential books on the syllabus.

At the University of Michigan School of Public Health, I then learned to connect the dots between our environment, our socioeconomic status — especially the role of education — and health.

Addressing health disparities is as much about access to health insurance as it is to access to good and well-priced food, safe schools, education, good jobs, and sound social policies about gun ownership and use.

These interrelationships are fundamental to public health thinking. Those of us whose work touches any aspect of health and health care must attend to public health and commit to reducing health disparities in America. A healthy populace is a more productive populace across so many dimensions. As we continue the hard work to re-build the national economy, public health should and must be seen and used as a pillar for economic growth.

 

This blog post is updated from previous versions that have run here on Health Populi to commemorate Martin Luther King, Jr.’s, birthday. 

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