Health Business Blog

As you’ve probably read by now in the New England Journal of Medicine (Full Coverage for Preventive Medications after Myocardial Infarction), so-called value based insurance design, which waives co-pays for maintenance drugs, resulted in only a modest improvement in medication adherence and failed to significantly improve the primary outcome of the first major cardiovascular event or revascularization.

Despite the waived co-pays and study leadership by big machers from Aetna, Harvard, CVS Caremark and the Brigham, medication adherence was still under 50 percent, an improvement of just 4 to 6 percentage points over patients who were faced with co-pays. The researchers’ conclusions are as follows:

Despite the improvements in adherence that we observed, overall adherence remained low… Therefore, interventions to address other contributors to nonadherence (e.g., knowledge, attitudes, the complexity of prescribed regimens, and difficulties that patients have in accessing their medications) will be necessary to adequately address this problem.

I see things a little differently.

Perhaps the trouble is that rewards for nonadherence under value based insurance design are too low and punishment is entirely absent.  Consider the following alternative study design:

• Pay those who are fully adherent $5000. If that sounds high, keep in mind that these patients incurred about $70,000 in costs on average during the follow-up period
• For those who aren’t adherent, provide counseling and warnings, and a reassessment of whether their therapy is optimal. If they still aren’t adherent, then cancel their insurance

Of course the second bullet point sounds terrible. But if we’re serious about controlling costs shouldn’t we at least contemplate punitive measures?

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Alvaro Fernandez of SharpBrains hosts the latest edition of Grand Rounds. He features an excellent set of posts on the usual range of topics such as improving care, health information and information technology, wellness, and physicians. There’s also a serious post about the health risks of bestiality.

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I’m pleased to learn that the super committee is seriously contemplating having higher income senior citizens pay more for their Medicare coverage (Kaiser Health News: Affluent seniors could take a hit on Medicare). I’m also intrigued that such a policy appears to have broad support from the public and policymakers at a time when regressive flat tax policies are in vogue and when the Bush tax cuts on high earners are expected to be renewed.

Medicare is financed in a regressive manner. Everyone pays a fixed percentage of wages toward Medicare. That includes many working poor who can’t afford health insurance themselves, yet subsidize health coverage for Medicare recipients of various income levels. High income people pay the same percentage of their wages into the system as low earners –so this is essentially a flat tax. However, Medicare tax is not collected on capital gains, which comprise a significant portion of the incomes of high income people. In practice this means low income earners pay a higher percentage of their incomes into Medicare than those who make the most.

Why is it that people seem willing to raise revenue from high-income Medicare beneficiaries when there is a reluctance to impose higher taxes on high-income people in general? Here are a few thoughts:

• Although raising Medicare premiums is essentially a tax increase, it can be presented as a reduction in subsidies, which is more palatable
• The working age population is very familiar with the concept of rising employee financial responsibility for health care at all income levels, so it seems natural to extend that concept to retirees
• There is (finally!) an understanding that Medicare is bankrupting the country and that we need to do something to keep costs down
• The Ryan plan, which calls for providing subsidies to Medicare beneficiaries to purchase insurance, has given people a sense that this kind of change is coming
• While people may generally buy into the vague (and in my view, false) notion that taxing high earners will reduce entrepreneurship and investment, they don’t think it applies to retired people

The Kaiser Health News article includes a couple of disingenuous arguments from the National Committee to Preserve Social Security and Medicare:

• “When you’re talking about seniors, the definition of wealthy seems to be a whole lot lower than when you’re talking about younger people”
• ‘Unlike Social Security, there is no cap on the annual income that is subject to the Medicare portion of payroll taxes paid by working Americans’

The problems with those arguments are as follows:

• The proposals are based on income levels, not wealth, which makes sense because it’s much easier for the government to measure individuals’ incomes. A retired person with an income of $150,000 is likely to have much higher wealth than someone who’s 40 years old making the same amount. I have no problem asking such folks to dip into their savings to contribute to Medicare
• It’s true there’s no cap on annual income subject to the Medicare tax. But that’s only been true since 1994. Most Medicare beneficiaries spent the bulk of their working lives under an annual Medicare wage cap

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On this Veterans Day, thank you to all veterans for your service to the country.

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At the recent Partners Connected Health Symposium I sat down with Dr. David Blumenthal, former National Coordinator for Health Information Technology. We discussed the unfolding impact of his work on Meaningful Use, the role of the patient, health IT in the UK, and the future of health IT funding considering the partisan divide in Washington.

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I’m experimenting with a new transcription service, which should be great but has been causing me some headaches so far. For now you can listen to the podcast and see the transcript. Depending on your browser and OS the recording may also be synchronized with the transcript –you’ll see a cursor in the text keeping pace with the audio. You may even be able to search the transcript and jump to the relevant portion of the audio.

Thanks for your patience.

DAVID WILLIAMS: This is David Williams, Co-founder of MedPharma Partners, and author of the Health Business Blog.

I’m at the 2011 Connected Health Symposium today. I’m speaking with Dr. David Blumenthal. He’s Samuel O. Thier Professor of Medicine, Professor of Health Care Policy at Massachusetts General Hospital/ Partners Health Care System, and Harvard Medical School. He was also the National Coordinator of Health Information Technology until earlier this year. Dr. Blumenthal, thanks for being with me today.

DR. DAVID BLUMENTHAL: Thank you for having me.

WILLIAMS: I’d like to ask you a few questions about the unfolding impact of your work from ONC. Maybe the first question is about the patient’s role in Meaningful Use. I think there’s been a lot of emphasis, especially in the early stages, on physician and hospitals, but I know the patient is in there somewhere. I would love to get your views on where that comes in.

BLUMENTHAL: Well the law focused on the provider, and it was a logical place to focus. If you wanted to get the health care system digitized, most information is in the hands of providers at this point. That’s also the group that can be influenced directly by public programs that pay for care.

When we have a substantial amount of information digitized, then I think the sharing of that information with patients becomes much more practical. The companies that are creating personal health records will actually have information that’s ready to be deposited, and then it will be more meaningful to have patient engagement in a much more proactive way. In the transitional period, the Meaningful Use standard did require an unprecedented level of electronic sharing of information. And I suspect that the next version of Meaningful Use will move further along that trajectory.

So I think we are working toward patient engagement. That’s one of the main aims of the meaningful use framework as it was initially proposed during the first phase of meaningful use. So I’m confident that it’s well integrated into thinking about meaningful use. The Office of the National Coordinator has a consumer eHealth office, and is planning to give it a lot more emphasis going forward, as I think is appropriate.

WILLIAMS: Now, interoperability has always been a priority for you, but also an area where I know there are some challenges. I wonder if you could offer a perspective on where we are on interoperability today, and what the future looks like over whatever timeframe you think is reasonable.

BLUMENTHAL: Well, interoperability is an order of magnitude more difficult as a challenge than accomplishing the adoption of electronic health records. I think we are well on the way toward the adoption. We are at the beginning, I think, of the sigmoid acceleration of adoption that is classic for new technologies. I think it’s already taken off for primary care. I think it’s going to soon take off for hospitals.

I’m reasonably confident that we’ve turned a corner on the adoption. On exchange, the challenges are fundamentally more difficult. It is because it is a collaborative activity. It’s not a individual activity. You have to have partners, and you have to work with partners, and you have to be willing to put the effort in to maintain those collaborations. That means there need to be incentives to do it, and rewards for doing it, and sustaining structures for doing it. Those social supports are much harder to develop than the technological supports.

So the Office of the National Coordinator’s working really hard to increase the number and usefulness of standards. They will be promulgated and adopted, and they will be incorporated into electronic health records. I would say that over the next three to four years, I’m hoping, that the full suite of standards that we need to create an interoperable health system will be in place.

There will need to be, as a result, upgrading of current records and current technologies to accommodate those standards. Then the question will be will the provider community use them? That is, will they implement the capabilities to exchange information, and work with their partners, their collaborators, to overcome the inevitable kinks in the system. I think that will depend as much on the social and economic forces at work as it will on the technological progress we make.

WILLIAMS: Now certainly in the early years after the stimulus law was passed, there was a lot of focus on people chasing the incentives before they expire. But there’s a penalty phase that comes in and I think does not expire. I’m wondering if you have a view on to what extent those penalties will actually motivate adoption, or the kind of behavioral change in that period that’s upcoming only a few years from now.

BLUMENTHAL: The penalties will be very motivating for hospitals because there are substantial amounts of money. For individual physicians, I don’t think they will be decisive. I think the individual physician will adopt ultimately because they view it as a requirement for modern practice. The money’s nice, the penalty is something to be avoided. But it’s really as much a signaling device as it is a real incentive.

The signal has now gone out loud and clear that the 21st century is the electronic age, and medicine can’t isolate itself from the electronic age. Especially for young physicians, that needs no explanation or justification. For older physicians, that’s where I think the money is a sweetener that will move them a little bit further than otherwise they would have gone.

WILLIAMS: With all be acrimony in Washington, it’s pretty hard to find something that Democrats and Republicans agree on, and I think in health care in particular. Maybe one area might be some version of malpractice reform, although that has different flavors depending on where you’re coming from. As far as I can tell, health IT is one of those areas where if there’s not consensus, at least there’s not so much rancor Democrat versus Republican. Do you have a sense of whether that is actually the case, and if so, why that might be?

BLUMENTHAL: I personally believe there’s a great deal of bipartisan consensus in this area. There was danger of it being interrupted by the rancor around health reform in general. But my guess is that it will survive that test. My guess is that it will be one of the initiatives that the Congress will continue to support, maybe not as generously as it has in the past, but it will continue to support it.

People who really want to save money in health care are kind of forced into looking at information technology as a solution, and it’s just so logical, so elementary, so clear and intuitive that it’s needed. That almost anyone who’s serious about deficit reduction, constraining the size of government, improving the function of a health care system, eventually comes around to saying IT is not enough, but it’s really important.

WILLIAMS: I know you’ve closely watched the UK’s progress on health information technology. I’m wondering if you can give me a sense of what they’ve accomplished there, and where they’re heading in the UK.

BLUMENTHAL: Well the UK project is widely disparaged, and I think was not, perhaps, managed as well as it could have been. But we shouldn’t forget that 100% of general practitioners in the UK have electronic health records. We shouldn’t forget that they’ve used those records to dramatically improve compliance with quality metrics throughout their general practitioner sector. And that they have a very, very strong alliance between general practice and the EMR vendors in the UK such that, really, they are using their technology to advance health care goals and developing technology that can advance health care goals.

Where they fell short was in this effort to incorporate the hospitals into the electronic system. And they fell short, I think, because they treated it as a procurement project, rather than as a social change and behavior change project. That’s a very common and damaging mistake to make.

The spine they’ve created, the separate communication technology that they put in place, may turn out to be a great gift to their system. I think the verdict is still out on that. And they have made progress. So I wouldn’t discount the fact that they will be moving forward rapidly. But they made some tactical errors in implementing the system as it was conceived.

WILLIAMS: Well, we’re at the Connected Health Symposium here in Boston, and I know that you participated today on a futurist panel. I’m wondering if there are any key take-aways that came out of that session.

BLUMENTHAL: I thought the panel we had showed a wide range of views and concerns. Maybe the major message was that IT is in the eye of the beholder. There are so many specific technologies and specific uses of those technologies that are encompassed under the term health information technology that it’s easy for people to sit next to each other on a podium and talk about rather different phenomena, and rather different technical needs, and very different care needs, and rather different policies.

So on the one hand you had a company like Verizon, which is trying to think about the use of wireless and cloud-based technologies for enhancing the sharing of information, and runs this huge communication network worldwide. A great resource, a very important company to be involved. On the other hand, you had a geneticist and computer scientist who is thinking about using networking theory to build more complete views of genetic, and physical, and population explanations of diseases. And I was talking about how the 2012 election is going to affect our efforts to create a health information network.

So I think it was indicative of the widespread ferment, and creative ferment, in this field. It’s a very hopeful time. A very dynamic time. It’s almost like the clam shell has opened in health care, and suddenly we are beginning to experience the world that has existed around us for several decades, and it’s going to shake things up and stir things around. And that’s all to the good. It’s just going to be a lot for the average doctor to digest.

WILLIAMS: I’ve been speaking today with Dr. David Blumenthal, formerly National Coordinator of Health Information Technology. Very interested to hear what you’re going to be up to next. I’m looking forward to when you can make that announcement. Meanwhile, thanks for your time today.

BLUMENTHAL: Thank you. Good luck to you.

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InsureBlog hosts the Olio edition of the Health Wonk Review.

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Kaiser Health News and NPR found a request for information letter from Walmart to prospective partners saying the retailer was seeking help to “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.” When asked, Walmart denied that it had such an objective.

Walmart is probably planning to build a network of in-store clinics that are a lot like MinuteClinics. Walmart’s already had a couple false starts in this arena and there’s no great reason to be confident that it will be successful this time around. Most people seem to think Walmart mainly wants to boost retail traffic.

As the article points out, primary care is not where the costs are. Rather, the big money is in specialty physicians and hospitals. I’d like to see Walmart de-emphasize its me-too store clinic strategy and do something bold and potentially impactful.

Open a hospital for instance. Maybe partner with Toyota or Apple to do so.

Ok, I know it’s a completely impractical suggestion, but I would really like to see someone apply Walmart’s supply chain and retail expertise, Toyota’s process engineering and Apple’s design philosophy toward health care. Rather than start with the presumption that everything is going to be expensive, complex and opaque, go for a lean, mean, yet elegant structure.

It’s probably impossible to build such a facility in the US. But maybe the first one can be set up just across the border in Mexico, drawing traffic from north and south of the border –probably self-pay and high deductible patients to start. Staffing will clearly be a challenge, but with the right setup it could become an attractive place to work.

The Walmart $4 generic issue was a bold move. Copying MinuteClinics is not. Why not go for something more worthwhile?

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Kaiser Health News tries hard to understand Mitt Romney’s Medicare plans and ultimately concludes it’s difficult to figure out what it all means. Not surprisingly, Romney is none too quick to get into specifics. And from his standpoint why should he? With a collection of extremists and perverts running against him, it doesn’t make sense to be too specific on an issue that’s likely to lose him backers. Still, it’s clear that Romney is proposing a version of the Paul Ryan plan that would turn Medicare from a defined benefit plan to defined contribution. He’d offer more “premium support” to those who are older and sicker and would probably push back the eligibility age a bit. He’d hope for competition among health plans to control prices. And –following the wishful thinking/let’s please everyone template of Rick Perry’s flat tax– he’d let those who like the current fee for service system to stick with it.

Romney’s plan won’t save much if any money, and he must realize it. To do that would require changes to the payment and delivery system that I’m sure Romney doesn’t have any appetite for.

I think Romney, Huntsman and Gingrich could have a serious and informative debate about Medicare policy if they wanted to. The optimist in me thinks maybe Cain, Perry, Bachmann and Paul will get out of the way to allow that to happen. Stay tuned.

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The latest edition of the Grand Rounds blog carnival is up at Better Health. This is the Myth Buster edition so prepare to adjust your views.

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This is the transcript of my recent podcast interview on minimally invasive hysterectomy.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Bob Darrow.  He’s an OB/Gyn in Dallas, Texas.  He’s at Presbyterian Hospital and is on staff at the University of Texas Southwest Medical School.  Dr. Darrow, thanks for being with me today.

Dr. Robert Darrow:             Thank you David.

Williams:            I understand that about 80 percent of the 600,000 or so hysterectomies that are performed in the U.S. every year are done with open surgery but that something like 95 percent of those could be done with minimally invasive approaches.  Is that the case and if so, why are there so many open surgeries?

Darrow:            That does seem to be the case these days.  I think the reason for so many open surgeries is lack of training.  Most people in their training as a resident only learned the open way or they learned how to do a vaginal hysterectomy. The vaginal hysterectomy becomes difficult for a lot of people who don’t do them often, especially if they have to retrieve or evaluate the ovaries on each side.  The abdominal approach seems to be the easiest approach for most surgeons to learn and to execute.

Williams:            So it’s more about what the surgeons are comfortable with and what’s easiest for them as opposed to an overall assessment of what’s best for the patient or most effective economically?

Darrow:            In my opinion that’s probably the case.

Williams:            From a patient’s standpoint, what’s the difference?  Does it matter if they have an open surgery versus a different approach?

Darrow:            An open surgery is often done when there a lot of difficult pathology is anticipated, meaning a lot of scarring inside or things are stuck together.  A vaginal approach is usually reserved for women who have had multiple births where their pelvic support system is not as adequate, so things are going to be more relaxed and fall out.

The laparoscopic approach seems to be more successful and could be done even with these larger cases that I just described.  I think the doctors simply aren’t as familiar with them.

Williams:            Is it better for the patient in terms of their recovery or their prognosis?

Darrow:            In my opinion, the laparoscopic approach is usually the best because there’s less pain and a faster recovery.  With the vaginal procedure, there’s tugging and pulling on the vaginal support system which, in my opinion and that of others, creates a little bit more pain, but the recovery is almost as swift as the laparoscope.

The abdominal or open approach is the most extensive as far as recovery, sometimes taking six to eight weeks. It requires a longer hospitalization, which makes it more expensive and also more painful.

So in my opinion, the laparoscopic or the vaginal approach are much more comfortable for the patient. If the surgeon is skilled enough to do one of those, it’s preferable from the patient point of view in terms of getting back to work faster, saving money and having an easier recovery.

Williams:            Are there multiple laparoscopic approaches or is it just one specific approach or technique?

Darrow:            There are basically three laparoscopic approaches right now.  The first approach that became the popular earliest was a laparoscopic assisted vaginal hysterectomy in which they started dissecting the tissues down to the laparoscope, then ended up pulling everything out through the vagina –kind of like a modified vaginal hysterectomy.

With time, going into the 1990s, the instruments were better and we started doing laparoscopic hysterectomies where we had basically three ports –three separate incisions– one at the umbilicus and one in each lower quadrant. The right lower quadrant and left lower quadrant went through muscles, but were used for exposure and manipulation –like extended arms of the surgeon– and the umbilicus had the eyes of the surgeon or the laparoscope.  This became more popular and the recovery was much less.

We’ve now developed a single puncture hysterectomy where we can put all three arms or ports in through the umbilicus or belly button. Since we don’t have to go through the muscle, this is a lot less painful in my opinion. The recovery is faster and these patients are going home in two hours whereas a lot of people with the three puncture laparoscopy were staying overnight.

The newest approach besides the single puncture is the robot, which is also through the laparoscope. But the robot has four or five puncture sites.

Williams:            Is there any downside to this single puncture approach?

Darrow:            The main downside right now is the inability to see the entire area that you need to see if the uterus is difficult.  In the really difficult cases it may not be the best approach.  When I say “difficult” I mean extensive pathology.  I always tell my patients that we start out with one puncture through the umbilicus and if we have to add one or two more we can do so.

The single puncture hysterectomy seems to work best in uteruses that are not quite as big and not as stuck or scarred.

Williams:            I imagine if you’ve got a surgery that takes less time to recover from, that’s probably less costly economically and the woman can get back to work sooner. But are there also any losers from an economic standpoint that might stand in the way of allowing this approach to go forward and become more prevalent?

Darrow:            You would like to think that it would become more prevalent as more and more people know about it.  Everybody seems to like the idea of having surgery with less pain and a faster recovery. As the learning curve of the physicians improves with the new technology, I would like to think that more and more physicians would embrace this technology that comes with less pain, less cost, an less time away from work. It seems like a win-win-win situation.

Williams:            My understanding is that various OB/Gyns such as you have come together from competing practices in Dallas to work on this issue of less invasive hysterectomy.  Can you tell me about what’s going on there and what the motivation is for that?

Darrow:            In the three-prong laparoscopic approach you’re absolutely correct.  There’s a group of us from Dallas Presbyterian Hospital who have applied for and received a certificate of excellence through AIMIS, The American Institute of Minimally Invasive Surgery. AIMIS recognizes us as a leader in laparoscopic hysterectomies.  Of this group, I am the only one that does a single puncture and as far as I know, the only one in North Texas that is doing it since this is frankly new technology. But there are many of us that are skilled laparoscopists with the three-prong approach. And yes, we do talk among ourselves and try to share secrets. A friendly rivalry makes all of us better.

Williams:            If someone were told they need a hysterectomy, what advice would you give them?  Let’s say they’re not in your neck of the woods.  What should somebody in another city be thinking about?  What questions should they be asking and what should they be looking for?  It sounds like not everyone is getting it in the most optimal fashion and different surgeons are trained different ways.

Darrow:            Anytime a patient has to make a difficult decision they need to know what the options are from their physician. They need to know the risks and benefits of each option including: pain, potential complications of the surgery, recovery, healing, back to work.  The bottom line is some physicians just don’t have the skill sets that other physicians do. But if they have the trust of the patient, that may be more important to the patient.

Williams:            I understand you’re working with a new technology.  Is there a body of research –either established or emerging– that supports some of the experience that you’re having?

Darrow:            Absolutely.  There’s a body of research otherwise I wouldn’t have started this way without the research to help support me.  Understand that the hysterectomy is a long and proven operation.  All we are doing with our technology is developing newer instruments that make our job easier, whether this has been from day one with the improvement of surgical instruments for open abdominal hysterectomies all the way through vaginal hysterectomies and laparoscopic hysterectomies.  We physicians are always made better by the research that we do and the observations of our complication rates versus success rates.  Certainly you don’t want to have a procedure that has a high complication rate.  Fortunately so far none of these did.

Williams:            Are there other topics that we should cover today?

Darrow:            I think we’ve done a good job of covering it.  I think patients have to always know what the risks are of surgery.  Also always try to resort to non-surgical remedies first in my opinion.  Surgery should be a last resort and you have to weigh the factors that affect your life.  Patients need to be aware of all the options available to them and why their physician chose one over the other.

Williams:            I’ve been speaking today with Dr. Bob Darrow, an OB/Gyn in Dallas, Texas.  We’ve been talking about minimally invasive approaches to hysterectomy.  Dr. Darrow, thanks for your time.

Darrow:            Thank you very much David.

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