Coss Effective

A few years ago, a friend of mine, and Cardio-Thoracic Surgeon, told me that his latest offer from an insurance company for coronary bypass surgery reimbursement to its membership was $1,800 dollars.  He since left California and is practicing in Indiana.  Those physicians less enclined to head to the midwest are getting innovative by provideing services for which patients (now customers) will pay cash.  My wife’s Gynecologist, for example,  just began a physician supervised weight loss program for her patients.  Family practice physicians are learning how to give Botox injections while offering other services.

Earlier this month an innovative new company out of Southern California launched a simple to use program over the internet to help dermatologists and cosmetic medical physicians market to their own patient base.  AppointYou uses advanced cloud computing services that allows medical practices to market directly to their patients by email, text messaging and even voice mail.  What’s amazing about this service is that it is highly specific to patient by age and gender, and about one third the cost of mailing post cards.  The result is that with tools like AppointYou , medical practices can create some relief from diminishing reimbursement, while providing additional services to patients who are willing to pay for them on their own.  “We’re initially focused on dermatology and cosmetic medicine because they’re in the front edge of this curve” says Ken Forbes, Founder and CEO of AppointYou, “but the tool we’ve developed works for any discipline seeking to provide additional services to their patients.  We are driven by our customers’ needs, not limited by the platform we’ve developed”. 

You will see more of this as healthcare reform begins to change the dynamic of how healthcare is currently being funded.  The good news, is that the healthcare market place remains vibrant and physicians aren’t sitting by idoly watching their hard earned training go to waste.

Earlier this week I was listening to an interview with Jared Bernstein, Chief Economist to Vice President Biden.  The interview with Neil Cavuto of Fox News, was noteworthy by virtue the answers Jared was providing to some fairly straight forward financial questions.  This provoked me to go to Wikipedia to look into his credentials and there I found my answer.  Jared Bernstein is a handsome and articulate gentlemen, but he is in the end a social worker.  Undergraduate in music (Base), Masters in Social work and Ph.D. in Social Welfare.  The Wikipedia entry ends with : ”he has no degree in Economics”,  yet he is presented as an Economist. 

I mention this with no disrespect to Dr. Bernstein, but that words have meaning, and a Ph. D. in Social Welfare doesn’t mean a Ph.D. in Economics or that Jared knows the difference between an income statement and a balance sheet, or the cost consiquences of the policy decissions he and his boss may be suggesting.  This is deceteful and misleading.

The best way to gain money and power in Washington, is to carefully craft a non-problem, attach a sense of utmost urgency to it, and sell the nation that you are the best and only solution to this newly crafted non-problem.

Secretary Sebelius has done precisely that with her assertion that women are getting gettint the short end of the stick when it comes to healthcare http://healthreform.gov/reports/women/index.html, the problem is that the evidence is weak, and emperically doesn’t work.

In 2006, the last year for which we have complete data, there were 16.3 million hospital discharges of male patients and over 23 million female discharges.  Lest you think that this is because of having children, which does contribute, in the over 85 cohort, hospital discharges ran 986,000 for men and 1,982,000 for women. 

Sebelius’ arguement also shows a biologic difference between men and women in that premium charges are different.  Should this not make sense, doesn’t the term “insurance” imply some offsetting of risk?   Quoting from a study entitled Roadblocks to Healthcare: “In particular, women are often charged higher premiums than men during their reproductive years. Holding other factors constant, a 22 year old woman can be charged one and a half times the premium of a 22 year old man.”  Ok, so what?  We get it, men and women are different.  If I were a professional sky diver instructor, don’t you think my life insurance premiums might be a bit higher? 

Still, don’t trust me on this, go to any home for the aged and count the number of women to men.  Sit inside any emergency room and count the number of  women and men patients.  Unless you’re at a Veterans Hospital, you will see the real truth.  Women consume far more healthcare than do men, live longer and take better care of themselves. 

It is approaches like this from appointed stewards of our government that cause people to be distrustfful of their proposed solutions.  This is shameful nonsense and precisely why the government needs to get out of healthcare. 

Tom

The banking and finance industries were among the first to make extensive investments in information technology.  Perhaps no other industry has done more with detailed information technology. You can see that in your own experience of ATM’s and now web access to your accounts.  Checks clear in a matter of hours and personal credit cards are accepted virtually everywhere in the world.  If you were to think of industries in which there is an abundance of information from which sound decisions can be made, the finance industry would likely rank among the top, yet after all the detailed information across decades, the finance industry did not forsee the problems in which we now find ourself.

In the book the Black Swan, Nassim Taleb points to many failures of financial decisionmakers in their paying attention to details, in particular their propensity to depend upon exotic financial equations in providing them guidance in their decissions.  The challenge we have in Dr. Taleb’s book, is that it was first published 2 years ago and described with great clarity what we are experiencing today.  So what are we to make of this?  What does the lessons of the current financial crisis have for those seeking similar metrics for the future of healthcare, namely Comparative Effectiveness measurements.

First, this is not to suggest that we shouldn’t look into the effectiveness of new products and procedures, but it is a warning to those that place such great hope that such analysis will save money.  It may, but it very well may not.  Truth be known, medicine isn’t much better than the financial industry at predicting the future, and we don’t have nearly the data that the financial industry has.  Healthcare is arguably 20 to 30 years behind the banking and finance industry in regard to their information systems and the information they produce.  Imagine the leap of faith required to think that medicine can do better than the financial industry with less experience, less information and an eminently more complex biologic processes.  Just how are we to believe that?

Medicine profits heavily from surprise and we benefit by capitalizing on the unexpected.  I think of small and powerful things like Folic Acid during pregnancy that lowers the incidents of neuro tube defects.  Or a failed antihypertensive drug that later became Viagra and is now used with great success in the treatment of patients with pulmonary hypertension.  In what possible way could these beneifits be discovered ex ante?  In the end, it is the hight of hubrice to begin to think that we have all the data we require along with the ability to analize it, and in so doing apply Comparative Effectiveness metrics to lower costs while improving outcomes.  This, ladys and gentlemen, is what they call in Basketball a “head fake”.

Unlike choosing between Asperine or Tylenol when you have a headache, decisions regarding cancer treatment and knee surgery have longer term consequences, and understanding the distribution of those consequences takes time and a lot of examples. People don’t much like being test subjects, but to some degree we all are when it comes to conventional wisdom and treatment choices. What is unfortunate, is that it is difficult to look back over time, and across a large population of patients to see if stuff works. The answer is there, but invisible because the data is not acquired and usable.

This is where Comparative Effectiveness (CE) and healthcare information systems come together.  CE has lots of promise in improving the utility of some of the treatment decissions we make.  I recall a time early in my RN career, that it was thought to be good for stomach ulcers to drink Half&Half, and indeed many physicians ordered that along with antacids for the treatment of peptic ulcer disease.  Now, just 25 years later we look back on that with astonishment as to how medicine could have gotten it so wrong.

Remaining is the  issue of human nature and how we are going about to capture the necessary information from which we hope to gain so much valuable insight.  This, as the cartoon on the right illustrates, is step 2.

Tom