Health Business Blog

The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on April 18, 2007.  Mini-meds look dead due to health reform, but depending on how things goe they may come back. If you’d like to comment, please do so on the original post.

I’m not enthusiastic about Mini-Med plans –the policies that offer limited coverage, often capped at $25,000 to $50,000 per year. In some ways they are the opposite of insurance because they pay for routine expenses but don’t cover catastrophic ones. In fact, I’ve come out repeatedly in favor of scrapping insurance for routine costs, like prescriptions.

I have to admit there’s another side to the story, and admit that my personal perspective on this has been colored by the fact that I can afford traditional coverage.
The Wall Street Journal ran a very informative piece on page 1, today (Covering the Uninsured, But Only up to $25,000). It focuses on Tennessee’s state-sanctioned mini-med coverage, CoverTN, and repeats some of the common criticisms:

Alan Sager, a professor of health policy at Boston University, calls the Tennessee plan “flimsy insurance” that will merely “provide cover for employers to save money.” Adds University of Tennessee medical-school professor David Mirvis, “It may be better than nothing, but it’s not real insurance.”

These experts are right.

On the other hand:

…Gov. Bredesen says he listened to focus groups and queried blue-collar folks, such as a waitress at a waffle restaurant, to devise his plan. “They weren’t interested in buying insurance for catastrophic events. They wanted access to the emergency room next month, access to the pharmacy next month,” he says. “Let’s give people what they want instead of what some advocate says they want.”

What Bredesen understands, but Sager and Mirvis downplay, is that a $10,000 or $25,000 or $50,000 debt falls into the “catastrophic” category for a lot of people. It can mean filing for bankruptcy or taking many years to dig out of debt. There’s not such a big difference between owing $50,000 and owing $1 million. Both amounts are in the category of not being repayable. Many people who run up debts of either amount are going to be eligible for Medicaid in any case.
On the other hand, if a person of modest means buys a comprehensive policy, it’s likely to be expensive and have high deductibles and co-pays. In addition to having to scrape together the money to pay the premium every month, a moderately expensive episode of care could still end up causing financial hardship or ruin.

For example:

Sherry Slatton, 46, a nine-year veteran in the Pepper Patch kitchen, dropped her comprehensive health insurance through her husband’s employer. The couple enrolled in the CoverTN plan, and their monthly cost will drop to about $175 from $350. Ms. Slatton wasn’t happy with the old coverage, which she says stuck her with $4,000 in charges when she underwent surgery to remove a benign cyst.

There’s also a stigma associated with being uninsured, and Mini-Meds address that, at least to some degree:

Ms. Robinson, the 23-year-old kitchen worker, figures it can’t get any worse than being uninsured. A nonprofit clinic recently told her she couldn’t get an appointment for a sinus problem for three weeks. Last summer, she went to a hospital emergency room for an infection. She says she was treated rudely, never saw a doctor and couldn’t get a prescription for an antibiotic from a nurse. Now, she’s paying $47 a month to the hospital to pay off her $3,000 debt. Her CoverTN premium is $41 a month.

“You walk in the hospital without insurance, it’s like you don’t even matter,” says Ms. Robinson.

I still dislike Mini-Meds –especially those sold by companies that engage in deceptive marketing practices– but we should acknowledge that not everyone who buys them is irrational or uninformed.

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on December 23, 2009. I took a lot of undeserved flak for this one. Maybe people thought I was being disrespectful toward nurses. If you’d like to comment, please do so on the original post.

In Nursing crisis looms as baby boomers age, CNN Money repeats a well-known story: there are unlikely to be enough nurses to take care of people as they age. Nursing schools can’t keep up with the demand and trouble awaits. We’ll face a shortage of 260,000 RNs by 2025, we’re told.

I don’t really believe it’s such a big deal.

There are two good solutions to the problem, and they aren’t mutually exclusive:

1. Increase the recruitment of nurses from abroad
2. Substitute technology for labor

The first option is already in effect to some extent. But anti-immigrant attitudes and rules limit the number of non-US nurses here. There are also an ethical considerations; when nurses from middle income countries like South Africa and Thailand come to the US, it creates a shortage of nurses in those countries. Some of those shortages are filled by bringing nurses from poor countries to middle income countries. That leaves the poor countries bereft at a time of tough challenges such as HIV and TB.

The second solution essentially means replacing at least some nurses (or some of their functions) with technology, including robots. A lot of things nurses do will be doable by machine, if not this year then certainly by 2025. These robots will take many forms, but one could certainly be as a “personal medical assistant” that handles most mundane functions. It could check vitals, provide encouragement, remind patients to take their medications, and go beyond those tasks to other areas, such as playing games, cleaning the house, making food, and even engaging in pleasant conversation.

This technology trend shouldn’t encounter too much resistance from nurses, who after all should still have plenty of opportunities for employment.

The nursing workforce issues are real, but they provide opportunities for innovation, not cause for panic.

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on August 9, 2007. I was into medical tourism at the time, traveling to Singapore and South Korea to check it out for myself. If you’d like to comment, please do so on the original post.

Until now, medical tourism has mainly been a self-pay phenomenon. But over time the patient base has expanded from the plastic surgery crowd to the uninsured and underinsured. Now health plans and employers have started to ask what role medical tourism can play for them. We’ve been receiving a number of inquiries on the topic at my consulting firm, MedPharma Partners. Soon we’ll be developing a medical tourism white paper. In the meantime, here are some questions health plans and employers should be asking:

1. Should I include overseas providers in my network at all? If so, which ones?
   • For some payers the time is now. For others waiting to learn from the experience of others will make more sense
   • The providers that are popular with self-pay patients may or may not be the right ones. Proximity, local infrastructure, quality and capacity may be more important considerations for employers and health plans
2. How should I engage my employees or members? Should I require patients to travel or should I make it optional?
   • The moment health plans and employers start to encourage the use of overseas providers they will be met with suspicion, but there are ways around this. Making overseas care optional will reduce the suspicion but limit the savings
   • It’s important to let prospective traveling patients engage with their peers. That’s one objective of the forums at MedTripInfo
   • It can also make sense to share some of the financial benefits with employees and members or simply to grant them additional vacation time, which they can enjoy overseas
3. How do I guarantee quality and overcome the challenges of patient safety?
   • You might want to ask this of your local providers, too! But seriously, there are international accreditation bodies like JCI. Also, many overseas hospitals are going over and above those requirements
4. What about medical malpractice and liability?
   • That’s a tough one to address and we’ll see what evolves. There are promising approaches emerging involving arbitration and insurance for complications
   • This may be a hard argument to make, but patients actually don’t have great recourse in the US when things go wrong. Cases take several years to reach trial and plaintiffs usually lose, unlike in other personal injury cases
5. How will pre- and post-travel care be coordinated?
   • This issue needs to be addressed differently depending on the procedure and patient population
   • It’s essential to work with your existing provider network rather than handling medical tourism in a vacuum
6. Should I contract with providers directly or work through an aggregator?
   • It will be difficult to develop and maintain a comprehensive network on your own so working with one of the emerging provider networks is a better idea
7. What procedures and treatments should be included?
   • This will depend on your patient population but it will generally include orthopedic and cardiac surgery
8. How much am I likely to save and how can I increase that number?
   • Most of the estimates tossed around, touting “90% savings” and so on are based on a comparison of US charges with the price paid overseas. First of all, only the uninsured get stuck paying charges, plus you’ll need to factor in the costs of travel –maybe also for a companion. I haven’t seen a really good estimate of the true savings potential for an insured population
9. How will domestic providers react?
   • Depends on how they’re managed, and this is one place where the interests of health plans and employers may diverge. Health plans may want to use the threat of sending patients abroad in order to beat down providers on price. Employers are more interested in maintaining relationships
10. What is the relationship between medical tourism and consumer directed health plans?
    • In theory patients with consumer directed plans are a great fit for medical tourism. In practice, they may blow through their HSA even at steeply discounted international prices, so it may not make that much of a difference
11. How well does medical tourism fit with limited benefit/”mini-med” plans?
    • Potentially very well. It offers the opportunity to include a major medical component at an affordable price

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on September 21, 2006. I saw the $4 generic announcement as a big deal at the time, and still do. If you’d like to leave a comment please do so on the original post.

No one seems to have an answer to high and rising health care costs. A parade of solutions –managed care, disease management, health care IT, pay for performance, consumer directed care and so on– are tried, but nothing really works. Costs continue to rise at double digit rates with no end in site.

A big problem with health insurance now is that it covers everything, from the most routine items like checkups to the most expensive, like transplants. That coverage for everything has a way of distorting the market. If car insurance paid for gasoline, oil changes, wiper blades and car washes it would likely dull consumers’ shopping skills and boost costs by adding an administrative layer. Initiatives like “consumer driven auto care” wouldn’t change things that much.

Wal-Mart seems to have a strategy that could fundamentally shift the market: it’s making routine items cheap enough that insurance for them isn’t even worth the hassle. Today’s announcement of $4 generics is an important step in that direction. It makes the cash price lower than the typical co-pay. In-store clinics with low prices are the other component.

Why did Wal-Mart’s generic price announcement put such a dent in the stocks of pharmacy retailers and mail order players? It’s because those companies have been making very juicy profits on generics while payers weren’t noticing. Because of the dynamics of the insurance market, payers focus on getting patients switched over to generics from high-priced branded products. They haven’t really paid attention to the fact that while generic wholesale prices have been sliding due to the entry of many new players, prices haven’t been dropping at the retail level and payers haven’t been ratcheting down reimbursement.

Generics are a great market for Wal-Mart to play in because it can use its traditional supply chain management, scale and negotiating expertise. Even before today’s announcement Wal-Mart was selling many generic drugs below its competitors’ cost of acquisition, just like it does in other segments. It’s true that only cash customers –a small segment of the market– are directly affected by the announcement. But the long-term implications are significant.

In-store clinics are the other area where we can expect some serious moves by Wal-Mart. The typical independent physician office is a lot less efficient than the mom and pop stores Wal-Mart has buried. Physicians aren’t exactly like store owners, but in some parts of the country they will have plenty to fear as Wal-Mart (and maybe others) pull away patients for routine services and minor ailments. That will encourage patients to drop coverage for routine services (if they can) and enable health plans to set lower rates. I wouldn’t be at all surprised to see Wal-Mart start to hire significant numbers of doctors and put them to work in its stores.

If Wal-Mart can spur significant reductions in the cost of routine services and products, it will go a long way to cutting overall costs. It may also enable the emergence of appealing catastrophic insurance policies.

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on November 27, 2006. If you’d like to leave a comment please do so on the original post.

Generics are a bright spot in the world of health care costs. Safe, efficacious generics are available in an increasing number of key therapeutic classes. Producer level prices have been low for years. Thanks to Wal-Mart those low prices are now making their way through to patients. With Democrats in control of Congress, barriers to the introduction of generics are likely to fade.

But there’s a large and growing exception to the generic trend: biotech. Biotech drugs are an expensive and rapidly growing component of drug spending and the trend is likely to continue.
It’s hard if not impossible to make exact copies of biotech drugs and there’s no clear regulatory framework for their approval. According to the Wall Street Journal (Democrats’ Rx? Generics):

Some biotech officials argue that generics makers will need to redo all the studies performed by the original manufacturer, in order to guarantee their copycat products are effective and safe for patients. That would likely eliminate much, or all, of the price advantage offered by the generics rivals. “There is no way to characterize a biological,” says James Greenwood, a former congressman who heads the Biotechnology Industry Organization, a trade group.

You should take the self-interested statements above with a grain of salt. Still it probably doesn’t make sense to apply the same generic model to the biotech industry, even though it’s worked well for traditional drugs. Instead I suggest the following:

• Allow biotech drugs to be approved and marketed as they are now, without price regulation
• After patent expiration or after a certain number of years on the market, regulate price. The price could be based on cost of goods, a percent of the previous selling price, or some other mechanism

This would avoid the costs and risks of biogeneric development and regulatory approval while delivering the benefits of lower costs to payers. The original maker of the product should be happy too. Although their price will be lower than it is today, they won’t have to share the market with generic players or spend money blocking the entry of new players. They will still enjoy a substantial period of high margin sales as they do today. It just won’t go on forever.

When, at some point in the future, science improves to the point where truly identical biogenerics can be developed, these rules could be revisited.

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The Health Business Blog is on summer vacation until Labor Day, and will be re-running some classic posts from now till then.

This item originally ran on January 11, 2008 and has had perhaps more profound impact on certain individuals than any other post I’ve run. Read the comments section of the original post and you’ll see what I mean.

A short paper in the current issue of the Journal of Child Neurology (Hypokalemic Sensory Overstimulation) raises some tantalizing possibilities:

• In some patients, ADHD may be caused by an excess of sensory stimulation arriving at the brain, rather than being a disorder of the brain itself
• For such patients, potassium supplements may be an effective treatment
• ADHD symptoms may indeed be triggered by sugar in some people
• ADHD and PMS may be related in some women –and their PMS may also be treatable with potassium
• Dentists may be well-positioned to identify possible ADHD patients

Conventional wisdom is that attention deficit disorder results from a problem in the brain. This seems reasonable since the stimulants used to treat ADHD work on particular pathways in the brain. But conventional wisdom is not getting much traction: researchers have studied the genes in these dopamine pathways and found only weak effects on ADHD.

Now, a group of Harvard-associated doctors –including Health Business Blog contributor Michael Segal MD PhD– has suggested a different model for ADHD based on an excess of sensory stimulation arriving at the brain. They came up with this model by stumbling across a family with some peculiar issues, and by having the background to understand the importance of what the patients were describing. Interestingly, they were able to treat the ADHD with a simple over the counter medication – potassium supplements.

The authors were not originally focused on ADHD. They were drawn into the area when a woman described to a neurologist that one of the core features of ADHD, a sense of being bombarded by sensory input, suddenly went away, –as if a shade had been pulled down.” This occurred 20 minutes after she took an oral potassium supplement for muscle cramps.

The neurologist was intrigued. It reminded him of the muscle disease hypokalemic periodic paralysis, in which ion channels in muscle become over-active when potassium levels in the blood are low. The woman described the factors that triggered her symptoms, and they were the same as those noted in the muscle disease: meals high in carbohydrates, food high in salt, and resting after exercise. Her son, who was having attention problems in school, also found the same triggers and got the same benefit from taking potassium.

Hypokalemic periodic paralysis is part of a family of “channelopathies.” Other variants were known in the heart (producing arrhythmias), in the brain (producing seizures), and in sensory nerves (producing pain). No variants producing ADHD had been described, and it would be difficult to suggest a channelopathy producing ADHD since the evidence in this family seemed “soft” –based as it was on subjective patient reports.

That all changed one day. The boy got a shot of the local anesthetic lidocaine for minor toe surgery, but he insisted that the numbing medicine wasn’t taking effect, even after repeated shots. The surgeon was skeptical but touched the boy’s toe lightly with his instruments and was surprised when the boy could describe exactly where he touched. The doctors knew that lidocaine works on sodium channels, and realized that an insensitivity to lidocaine would fit very well with a channelopathy causing sensory overstimulation. When the mother heard the details later that day she recounted that lidocaine hardly worked for her in dental procedures. Now the doctors had some objective evidence suggesting a channelopathy accounting for the core symptom in ADHD.

The way to confirm such a hypothesis is to find the gene for the mutant ion channel, which is hard to do using a small family. The doctors knew that it would take more families to do “positional cloning” to find the gene, and wrote up their paper, hoping to find other families. The paper appeared in early January and within days of publication another family sent an email to the contact address on the paper to describe a similar story in their family. If you have a story like that you may also want to make contact using the email address listed here.

Until the gene is found it is hard to say whether this sensory overstimulation form of ADHD is common or rare. Some factors suggest this clinical picture may be common – some people with ADHD think their symptoms are worse after consuming sugar, and occupational therapists describe a “sensory integration disorder” in many people with ADHD. One intriguing line in the paper even suggests that the sensory overstimulation may show up in ways that might not have seemed connected at all to ADHD: the mother “suffered for many years from strong menstrual pelvic cramping and noticed in her mid-40s that oral potassium supplementation blunted the menstrual pain to a dramatic degree.”

As people become familiar with the sensory overstimulation model of ADHD and researchers do the genetics we may soon have an understanding of ADHD at the molecular level and have new forms of treatment and prevention.

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This is the second half of the transcript of my recent podcast interview with Evan Falchuk, President and COO of Best Doctors. In Part I Evan shared his views on health care reform and information resources for patients and physicians. In this half he discusses Best Doctors, including a recent case involving his brother.

David E. Williams: I want to turn now to speaking about your company, Best Doctors. Please describe what Best Doctors is and what you do.

Evan Falchuk: We sell an employee benefit to companies that they give for free to their employees. We help people get the right diagnosis and the right treatment.  The way we do it is by collecting information from the patient, doing an interview, compiling records, having doctors analyze all the information and then consulting with experts from our Best Doctors database to figure out the right course of treatment.  I’ll give you an example in a second.

We find overall that about 20 percent of patients have something wrong with their diagnosis and more than half have something wrong with their treatment. Those are pretty extraordinary numbers, but there has been a very interesting body of public health research that has been coming out lately that supports almost the same numbers overall. So I think what we’re seeing is the reality of what it’s like to be in the health care system.

We’re a global business.  We cover people in more than 40 countries, representing more than 20 million people around the world. What we see is this problem of incorrect diagnosis and treatment happening globally in all kinds of different health care systems regardless of how people pay for care.

As an easy way to understand how it works I can tell you a story that is personal to me because it’s my own brother’s case.  We helped him recently.  We did about 10,000 cases in the last 12 months. This is just one but it’s powerful for me.  He is a little bit younger than me, not quite 40.  He is the co-creator of this hit TV show Glee that maybe you’ve seen on Fox.

A little while ago was diagnosed with a tumor in his spinal cord and was seen by a really leading neurosurgeon who said he’d do radiation followed by surgery on the spinal cord to take out what’s left of the tumor.

He called for help and we went through our process.  In looking at his record, our doctors found out that we have a family history of a kind of malformed blood vessel in the brain and that the neurosurgeon wasn’t aware of this problem.  But it was in my brother’s records.

My brother didn’t know it was pertinent but we said that it was. We asked an expert whether a tumor in the spinal cord be confused for one of these blood vessels and the expert said absolutely it could be confused, and what you need to do is do a different kind of test called an MRA in order to see.

So we delivered that information back to my brother and his treating doctor and they looked at it and said whoa, we have to stop what we’re planning on doing and look to the MRA. When they did they found out that he had one of these malformed blood vessels, not a malignant tumor.  He still needed a kind of surgery to fix this but if he had had the radiation on the bad blood vessel it probably would have bled, which probably would have paralyzed him or even worse.

But even if he had survived that, getting into the surgery, opening up someone’s spinal cord and suddenly you see something completely different than what you expected.  It’s a pretty bad place to be. Not every case is as dramatic as my brother’s case and actually he’s doing great.  He’s throwing out the first pitch at Fenway Park in two weeks.  That problem is symptomatic of what goes on in the system.  That’s exactly what Best Doctors addresses.

Williams:            That’s quite a compelling story.  I’m glad that he’s doing well.  It sounds like you are using essentially the same template that you had a couple of years back because in fact the underlying need hasn’t changed. Health reform and other things that are going on have not made a real difference to the kinds of issues that you’re addressing.

Is that correct or have you made some changes in the way you work?

Falchuk:            Well we’ve been growing a lot.  In the United States we’ve been signing up large employers like Northrup Grumman and other large corporations across the country. We’re putting this in as a fundamental part of their benefits offering and really leading with it and saying: look, if you’re worried about your illnesses or whatever it is you’re facing, call Best Doctors.

We are engaging more than ever now as early as possible in someone’s illness and staying with that member as long as possible after we’ve given our advice.  We are really acting as a navigator to help people figure out their way through the system and helping them coordinate their care, figure out where to go and what to do. That’s become an increasingly big part of our role.

And then the other big trend that we see in our work is the globalization of benefit offerings.  Many large corporations are multinational and buy their benefits historically in local markets. But increasingly these companies are centralizing that into their U.S. operations. We’re seeing a trend towards globalization, which for us as a global company seeps into what we do.

Those are the two big changes that have been happening over the last few years.

Williams:            What do you see as employers first get introduced to the service, sign up and people start using it?  Is there a path where they become true believers over time or is it just that people get it because they have their own story to relate?

Falchuk:            The sales process is always interesting.  When you go and you talk about what we do it’s very different from what people are used to hearing about in health care. In health care you hear a lot of theoretical ideas, whereas we’re showing up talking about real people and real situations. Everybody knows what it’s like to go to the doctor and not have enough time, and the challenges people face.

So that process is really the first thing. We connect with people because we’re talking about real stuff.  When we implement with an employer we always work hard to get the employer to engage and educate the employees.  We do that work.

We say: listen, it’s okay to be unsure about your care and if you are please call us and we’re going to help you and work with your doctor.  There’s always a big spike in use of our service right at the beginning because there is a pent up demand.  There are people out there daily that are facing these problems.

They’re suffering alone and don’t have a resource until Best Doctors comes in. So it is always eye opening and very quickly you start generating these kinds of stories. Imagine if you’re a big company and you’ve got 100,000 employees. There may be hundreds of people in the first few weeks that call Best Doctors for help.

Some significant number of them are going to have problems with their diagnosis and treatment. They call their HR department or they tell their manager: boy this benefit really made a difference in my life. It really makes what we do just tremendously satisfying when we get to hear those kinds of testimonials.

Williams:            Concierge medicine seems like another approach to the same issue. Can you comment on the extent to which somebody can achieve similar results with a concierge practice?

Falchuk:            It’s the notion of a practice where your doctor is going to have a much smaller number of patients.  That’s really what we’re talking about when we say concierge practices.  A doctor says I’ll see 500 patients not 5,000. The concept there is that your doctor is going to spend 45 minutes or an hour with you every time he or she sees you.  I think from what we see from our data that if a doctor could spend that amount of time with all their patients then a lot of our quality problems would be addressed.

Your doctor would really be able to act as your advocate through the system.  There was a time in history when your doctor was really the guy that you stuck with that really took you through things from beginning to end. But that time has passed.  So I think those kinds of practices try to replicate it and they make sense from an individual perspective.

I think it’s hard when you think about those as a policy issue. You would probably need ten times as many doctors in order to have everybody have access to the same level of care that you can get in that kind of a setting. That’s not a direction we’re heading in.

From a policy perspective, being a doctor today is probably as unattractive as it has ever been because your reimbursement is lower than it has been, the pressure to see more patients is the worst that it has ever been and the pay is probably lower on average than it has been compared to other professions. So we need more doctors and we need the doctors to be able to spend more time.  That really ought to be a fundamental part of how we look at the question that you’re asking.

Williams:            Those are the topics that I had laid out.  Are there other things that we haven’t covered that are on the top of your mind at the moment?

Falchuk:            It’s really important that anyone when they’re sick recognizes how important it is that they be an advocate for themselves and that they ask all the questions they think they need to ask and if they’re not satisfied that they keep going.  It is the only way to make sure that you as a patient are going to get the right care.

Williams:            I’ve been speaking today with Even Falchuk from Best Doctors about health care reform, patient navigation, advantages of Best Doctors and other topics.  Evan, thanks so much for your time.

Falchuk:            Great talking to you.

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This is the transcript of the first half of my recent podcast interview with Evan Falchuk, President and COO of Best Doctors.

David Williams:            This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Evan Falchuk.  He is President and COO of Best Doctors.  Evan, nice to speak with you today.

Evan Falchuk:            Great to talk to you David.

Williams:            It’s a been a couple of years since I had you on the blog and a fair amount has transpired in health care since then. Maybe we should start in with health care reform.

Let me just ask you the big question: is it going to work?

Falchuk:            I think it’s going to be a while before we know what works and what doesn’t work and whether it was worth all the trouble.

Williams:            Do you think there are some things that we’ll see in the early years?  Obviously this may be like some other legislation where the pieces come in over time.  Some PPACA provisions will phase in over the next several years but I wonder if you have any sense of the early indicators and where they may lead us.

Falchuk:            To the extent that the federal law was based on what we’ve done here in Massachusetts where I am – there will be some effect on the number of people who are uninsured and that will be a good thing.  It will reduce the number of people who don’t have coverage.  So that will be a positive short term effect.

The negative short-term effect as we saw here in Massachusetts is that there is still the same number of doctors before the law was passed as there are afterward.  So there will be increasing problems with access to care.

We have here in Massachusetts wait lists to see doctors, which is something we never had before. When someone gets coverage they are going to use it.

Williams:            Under health reform it sounds like it may be harder to get access to providers. Will it at least get easier for patients to identify who they should see in general and to determine who is best for the particular situation that they’re encountering?

Falchuk:            I think it’s hard, which is ironic because there is more information available now about medical care for consumers than probably ever in history. You would think that it would be easier for patients to navigate their way through, but I actually think it’s harder.

Doctors don’t have enough time with their patients and patients don’t have the level of expertise that they need to understand all the information that’s at their fingertips. So when you go to the doctor –and the studies show that the average visits are 15 minutes or less of face time with your doctor– it’s very difficult to engage on the issues that are important to you.

Patients say, ‘I’ve been diagnosed with something, I’m not sure what to do, I’ve read all the stuff on the Internet or in some social media and I need help sorting it out.’

Unfortunately your doctor is just not going to be able to do that effectively.  I think for patients it’s even more difficult to figure out, “Do I have the right person, am I going down the right path, am I asking the right questions?’

It’s not something that’s obviously addressed by reform in any important way and for consumers that’s increasingly a serious issue.

Williams:            If you look at it from the physicians’ side and the focus in ARRA on Meaningful Use of electronic health records, do you think that physicians will be in a better position to have the information and decision support tools that they need at their fingertips at the time of care to help the patient?

Falchuk:            Look, it will help.  Anything that will make it so that your medical records aren’t stored in handwritten notes in files that are buried in a storage facility someplace or in one of those giant wall units that move around is better, because the doctor will have more access to information.

But there is a real practical issue here, which is that if you’re going to get 15 minutes of face time with the doctor, there is even less time your doctor is going to be able to spend thinking about your case trying to assimilate all that information. So again as a patient if your issue is, ‘I want to make sure my diagnosis is right, I want to make sure my treatment is right, I want to make sure I’m on the right path,’ and you walk into the doctor and you feel like you have to introduce yourself once again to the physician and remind him of the issue that you’re facing, that’s the reality.

I think doctors will tell you the same thing: that it’s hard because you’re the 18^th patient I’ve seen today and between the last time I saw you and when I saw you this time I’ve seen 600 other people with similar problems to you, so it’s hard for me to exactly place you.

Williams:            Since we last spoke a couple of years ago Facebook has really taken off and there is Twitter and all manner of connecting with people.  Other than making for this increased flood of information that’s hard to deal with, does social media improve the doctor/patient relationship or make it easier for patients to navigate their way through?

Falchuk:            There is a lot of talk about what connections doctors and patients should have with each other. For example KevinMD has written about whether doctors should be friends with their patients on Facebook and where to draw those sorts of lines.  But in general social media is one of those things that’s given patients more access to information.

There are good websites such as PatientsLikeMe where as a patient you can find other people that are facing similar issues to you. That can help you know more and be more educated and also know that as a patient you can be your own advocate and stand up for yourself. You will find that maybe what you think is pushy with your doctor is really what you have to do to get what you need.

What I think is really interesting about social media from a policy standpoint is that a lot of  knowledgeable people were absent from the social media landscape during the debate over health reform. I mean people who are really expert in health care policy and the realities of paying for health care and what it means to be an employer who run programs that cover health care expenses.

A lot of people who were advocates for reform were less expert in these issues than the employers were. It was a missed opportunity for a lot of these groups to put their stamp on what reform ended up being, in order to have it be more in line with a lot of the innovation that’s happening in the world. Social media is the place where there is a lot of great stuff happening.

Williams:            There has not been a huge explosion in the number of quality rating sites over the past couple of years, but I know it’s a priority for federal and some state governments.  What do you make of some of what’s put on the web in terms of quality comparison sites?

Let’s say I wanted to compare two hospitals in the Boston area for a particular diagnosis.  Would I be in a good position to do that?

Falchuk:            You would not be, and I think it’s really unfortunate.  The government came out with its healthcare.gov website, which is meant to be more of an online insurance shopping site. But in the middle of it is a big section that talks about comparing quality providers. There is a tool there for comparing hospitals.

What was really striking about it (and I blogged about this) is that if you tried to compare one of the major teaching hospitals in Boston with a local community hospital in the Boston area, you couldn’t tell the difference between the two hospitals from the quality measures they were using  You just couldn’t.

And when you start to drill down, they don’t have any way to compare these providers for diseases like cancer.  The tools are really, really weak as far as what they can actually do for you, but they’re promoted in a way that says these are things that you should use.

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Toby Cosgrove, CEO of the Cleveland Clinic, worries that comparative effectiveness research will stifle medical innovation. I don’t think that’s likely.

I’m quoted in the Cleveland Plain Dealer today disagreeing with Cosgrove. Here’s what I said:

David E. Williams, a health-care business consultant and principal at MedPharma Partners in Boston, doesn’t see comparative effectiveness slowing innovation either.

“I think there are always concerns about whether payment policies are going to retard medical innovation,” Williams said. “But in practice, there’s been a strong willingness on the part of government and private payers to pay for new treatments.”

We should embrace comparative-effectiveness research, Williams said.

“It will make it more likely that things that are truly innovative will make it to market and it will discourage things that are flashy and expensive but don’t add much clinical value,” he said.

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In better times I used to hear people brag about California being the 5th largest economy in the world if it were its own country. Maybe it’s still true, but in any case the economic situation is a real mess. The latest impact is on Medi-Cal, California’s name for its Medicaid program. Due to a budget impasse, community clinics who rely on Medi-Cal for their funding won’t be receiving their checks. They’ll have to dip into reserves or borrow from banks and other sources. In essence, these safety net providers will be financing the state.

Kind of pathetic.

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