Health Business Blog

The Boston Globe published a graph showing that Massachusetts’ birth rate for mothers aged 15-19 is 17.1 per thousand compared with a nationwide average of 34.2. They didn’t mention where we stand against other states but a review of CDC data indicates that only our neighbor, New Hampshire has a lower rate. Vermont and Connecticut are also low. The highest rates of more than 50 per thousand are found in Mississippi, Texas, New Mexico and Oklahoma.

I’ll let others speculate on the causes of these disparities in birth rates. But I will say that having a low teen birth rate is a blessing for Massachusetts and indirectly allows the state to afford universal health care. Instead of having babies and often ending their formal education, women in Massachusetts are staying in school longer and ending up with higher levels of educational attainment. Boys/men also have a greater opportunity to stay in school when they are not burdened with paying for a child’s upbringing.

A population with more education attracts employers who pay higher wages. And these higher wages enable employers to offer health insurance and state governments to raise tax revenue that can be spent on education, health care and public health. It’s a virtuous circle.

Massachusetts, New Hampshire, Vermont and Connecticut are also in the top 10 states in terms of percentage of residents with health insurance. Of the states with a high birth rate, they all rate 36th or lower.

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By David E. Williams of the Health Business Group.

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The Saturday Evening Post has published a provocative article (How Doctors Die) by retired physician Ken Murray, making a strong case that over-treatment is rampant at the end of life. He describes anecdotes of physicians serenely accepting their death sentences and making the most of their last months and weeks compared with the average person who suffers needlessly and racks up a big bill in the process. Doctors understand the limitations of medicine in ways that typical patients don’t, he says, but have not been in a position to provide more appropriate care due to patient pressures, legal concerns, and the nature of the medical system. Hospice patients may live longer anyway, he adds.

I’m mainly on Dr. Murray’s side. I believe that over treatment is a big problem and that hospice care is underutilized. I understand the concept of never wanting to be put on life support. I am angered and saddened that the nonsensical “death panel” argument was used as a cudgel against ObamaCare by invoking the prospect of rationing of care.

And yet I’m uncomfortable with the article. First, to what extent should we accept the author’s anecdotes as evidence of the general state of physician perspectives? I don’t see a lot of systematic evidence for his contentions. Second, even if doctors feel that way should patients necessarily ratchet down their demands for services? I would say no.

My concern as a patient, caregiver or family member is about being written off when it’s not warranted. For example (since anecdotes seem ok, here) doctors discouraged a family member from chemo for leukemia due to his age, even though as I discovered the advice wasn’t really evidence based. He had chemo anyway thanks to our insistence, tolerated it well, and lived an extra year. It’s hard to figure out what tradeoff is reasonable to make between suffering and the potential to extend life even when all the information is in hand, which it rarely is.

And while it’s easy to oppose heroic, frequently futile measures and suffering in general, when it gets down to specific situations I’m not nearly as comfortable. Who’s to say a patient shouldn’t be willing to suffer in order to live a while longer and have a few more weeks or months with their grandkids?

The general point of the article –that those with the most knowledge of the limits and possibilities of medicine seek less of it than the general public in certain circumstances– is certainly worth contemplating. But I haven’t changed my own views after reading the piece.

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When I saw the MedPage Today headline, “Study: Docs in dark about complementary therapies” I assumed it meant that doctors didn’t understand these therapies. But the story described patients withholding information about what they were doing from their physicians. That’s not exactly a new or surprising finding.

The study advises physicians to ask about what else patients are taking or doing, which is probably a good idea. But I’d like to see more attention paid to how physicians react when they hear about other therapies and the extent to which they are willing or able to engage with the large percentage of patients that seek relief or cure outside the medical setting at the same time they are working with their doctors.

Some of these therapies are herbs or other substances that may interact with prescribed drugs. Doctors definitely need to know about that and deal with it. Other approaches, such as massage, meditation and reflexology may be helpful for some patients –and it may or may not matter if the physician is involved.

The best physicians take a personalized, holistic approach to their patients, and do so in ways that do not conflict with the evidence based mantra.  One physician I know has a medicine man (who’s also his patient) perform a ceremony blessing the statin he prescribes to another member of the same tribe. I’m willing to bet his patients are more adherent as a result of this approach.

I’m not a major proponent of alternative and complementary medicine, but I do find it revealing to see how physicians relate to other approaches, especially for diseases they can’t cure. Do they insist that other approaches are invalid and consider them an affront? Do they balance a healthy skepticism with open mindedness to the idea that they don’t know everything? Do they vary their approach depending on the individual patients and their situations?

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Short White Coat blogger Ishani Ganguli marvels at a frank UK ad (advert?) discouraging people with non-serious illnesses or conditions from clogging up the emergency room. It shows a line of people who shouldn’t be there. At the end is a wreath, representing a heart attack victim who should have been first in line.

She wonders aloud why we couldn’t have that kind of campaign here and answers that problems include access to primary care, the perception that going to the ED would be quick, and that primary care referred them to the ED.

These factors are all legitimate, but there’s more to the story. Emergency departments can be profitable and are a major feeder for inpatient admissions, so hospitals advertise them. You don’t have that in the UK. That advertising also leads to the perception that the hospital is a better place to be seen, so even patients who could get access to their primary care physician don’t try.

My health plan (Blue Cross) and others have what are euphemistically referred to as “demand management” services. In my case I can call and speak with a nurse who can steer me in the right direction, whether toward self-care, the emergency department, primary care, a specialist or the pharmacist. I’m not sure these things really save the health plans any money, but I also don’t know whether the UK ads work.

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A lot has changed since the last time I attended the Healthcare Information Management and Systems Society (HIMSS) meeting a few years back, but the biggest difference in my own experience at #HIMSS13 had nothing at all to do with health information technology. Rather, the big change was that even though I could only book 10 days ahead I was able to find low cost lodging close to the event, thanks to Airbnb, which describes itself as “a social website that connects people who have space with those who are looking for a place to stay.” Airbnb used information technology and social networking to completely transform my lodging experience from what it was only a couple years back. I’d love to see health IT transform health care to the same degree and as quickly. And although I do not believe health IT companies can just copy Airbnb’s model, perhaps some of the same principles can apply.

Here’s how things worked for me:

About 10 days before the conference I decided to go. But with 35,000 attendees –many coming from Boston– there were no flights whatsoever on Sunday, March 3, when I was available to leave, even if I had been willing to pay $1000 one-way. So instead I got creative and booked a flight from Providence, RI to Gulfport, MS. That wasn’t ideal, and it’s the same thing I would have done a year or two ago. I decided to stay in Gulfport, then drive or take a cab 80 miles to New Orleans on Monday morning. No rental cars were available for that trip so a cab it was.

Lodging was another story, with a happier ending. Hotels anywhere close to the convention center were sold out, although I did find a room at the Hilton for $900. No thanks. A couple years back I would have found a room 30 or 50 miles away or looked for a friend with a place there. But I remembering hearing about Airbnb and decided to give it a try. There were several listings for individual rooms and even whole apartments and houses within 3 or 4 miles of the conference. Many individual rooms were under $100. I signed up for an account, which took very little time, then followed a number of steps designed to increase trust and safety: I verified my phone number, connected via Facebook, Twitter and LinkedIn. I filled out a brief profile.

I looked through the listings, which included photos, bios of the hosts, and lots of reviews by people who had stayed at the specific properties, as verified by Airbnb. Most reviews were pretty positive, but hosts had replied to negative ones and gone into detail. I got a much better sense of what I was in for than anything I’ve encountered in health care. I selected a room for about $80 (< 1/10 of the Hilton price) and tried to book it. I sent a message to my host explaining why I was coming and letting him know I was a nice guy. This host had a policy, enforced through Airbnb, of approving prospective guests before accepting them. According to the site, most hosts reply within a couple hours, but they have up to 24. When I didn’t hear back within 2 hours I selected another spot, advertised as Street Car to Jazz Fest/French Quarter, which allowed instant bookings. This place was only $60 for a private room plus another $10 cleaning fee and $8 for Airbnb itself. The hosts’ extensive description gave me a good understanding of the place, mentioned free Internet, restaurants within walking distance, etc. Reviews were generally quite positive –and although it sounded much more like my hostel experiences from 20+ years ago rather than my more recent travel preferences– I decided to go for it. Information on Airbnb showed that the hosts, Robyn and Amanda responded to 100% of their listings, response time was quick, and that they updated their calendar frequently.

I was also reassured my Airbnb’s 24/7 phone support and various safety and security tips and guarantees.

I’m glad I went the Airbnb route. My hosts and I communicated over the Airbnb website but I also was given their phone number and email address. We coordinated my arrival time, they offered me a parking spot (which I didn’t need) and when I got there they recommended a close by restaurant that met my needs and suggested a cab company. (It was United Cab, which didn’t show up even after I confirmed and re-confirmed, but that’s not my h0sts’ fault).

I met a young French couple that was staying there for a month, and there were a bunch of law students staying there doing volunteer work. They were downstairs, though, so not bothering me. I had a good night’s sleep and was on my way.

Airbnb released my $100 security deposit within 24 hours and sent me a message asking for a review, which I provided and is now published. My hosts also reviewed me, so future hosts can see what I’m like (laid back, according to my hosts). And Airbnb let me communicate privately with the company if I had concerns I didn’t want shared or posted. (I didn’t.)

As I wrote, Airbnb’s innovations don’t translate directly into health care. There are some companies, including Castlight and ZocDoc that apply certain aspects of the model, including transparency of data and ease of booking appointments. Newer companies including Informedika and par8o are applying some of the principles to physician consultations and referrals. But there is room for a lot more and I’m hopeful Airbnb and other consumer Internet innovators will be inspirations. In particular I’m hopeful that new approaches will provide an alternative approach for providers that don’t want to be parts of big organizations.

In the meantime, Airbnb itself is making a contribution to health care by reducing expenses and increasing convenience of conference goers like me. No doubt it’s also being used by families who need to travel to other cities for medical visits.

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FDA just approved an implant for certain people with severely limited vision. This “bionic eye” does not restore sight but it does help “detect light and dark and help [people] identify the location and movement of objects.” So it could be a big help from a functional standpoint for certain individuals, even though it’s far from perfect and may not be completely safe.

Fast forward a decade or two or three and imagine a time when implants (or some other approach) can restore vision to normal. That will be pretty cool for the many people whose vision is relatively poor and there will likely be a lot of demand for such treatments/devices, even from people that we would not consider visually impaired today.

But then imagine that the technology keeps advancing and gets to the point where technology can improve on natural vision, so that someone with a bionic eye becomes more like the Six Million Dollar Man, especially if they get enhancements not just to the eye but to other body parts as well. I’m in my mid-40s and have a reasonable expectation of living to the time when this moves from science fiction to reality.

If you think about it, we are already starting to get there in limited cases.  Oscar Pistorius, now infamous for other reasons, shows that a double amputee can be as fast or faster as Olympic runners. How soon until other Olympians –who already commit their lives and bodies to the pursuit of excellence– will want body modifications to improve competitiveness?

Obviously the path of medical technology will raise all kinds of ethical issues. It’s time to start the discussion.

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It’s interesting to contrast the markets for new lawyers and new nurses and how those markets are portrayed in the popular press. Casual observers and reporters are willing to take it for granted that there is a shortage of nurses and a need to train a lot more of them. Students are responding by applying to nursing schools en masse and nursing schools are boosting enrollments. Reports that 43 percent of new nurses are unable to obtain jobs in the profession are explained away as recession related or irrelevant to the “looming” long-term shortage.

Lawyers are different. When it’s reported that only a little more than half of new law graduates get a job as a lawyer within 9 months of graduation, the Wall Street Journal rightly refers to a “lawyer glut.” Prospective applicants are getting the message and law school applications are down 30 percent since peaking a decade ago. On the other hand, those in the law school business are not giving up so easily. Nineteen law schools have been accredited since 2000 and several more startups are in the works. If these schools were smart they would take a page from the playbook of the nursing schools and support research to show why more lawyers are needed.

I’m not saying that the prospects for nursing jobs are as bleak as that for lawyers. But I do advise prospective students for any professional school to take a good hard look at job prospects before taking on a pile of debt and devoting several years to further schooling.

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