You are hereThe Healthcare Blog

The Healthcare Blog

Syndicate content
Everything you always wanted to know about the Health Care system. But were afraid to ask.
Updated: 10 hours 26 min ago

How to Calculate a VOI or ROI (if any) on Wellness

19 hours 49 min ago

In the era in which wellness vendors were still claiming an ROI on wellness (and more and more are not), I asked a number of them how they calculated the ROI. Not one calculated the ROI in a way that a steely-eyed CFO would endorse.

Below is a partial list of costs wellness vendors should be considering, but rarely if ever do consider. If you have a wellness program and want to look for an ROI please start with this list:

  • Wellness vendor fees
  • Communication costs
  • Investments in materials (i.e. Fitbit) and facilities (i.e. onsite fitness centers)
  • The cost of biometric tests and health assessments

  • The cost of program incentives (awards, premium reductions, etc.)
  • The wages and benefits of the company’s wellness team members
  • The wages and lost productivity for employees to sit through biometric tests, wellness meetings, to read wellness memos and other emails/communications, and the time to fill out health risk assessments*
  • The cost of following-up on false positives from asymptomatic employees going to doctors for ill-advised tests. This one is not uncommon – and can generate as much as $70,000** in additional cost and harm in a single episode.
    Further, when wellness vendors claim improvements in productivity, they need only look at a client’s wages as a percentage of sales (with a few minor adjustments). If that ratio is not declining, employee productivity is not improving. That is a simple calculation, but most wellness vendors claim that employee productivity cannot be measured – a fallacy.

For an excellent discussion on failures of wellness productivity claims click here.

The same principles apply to VOI claims as well. Click here for an excellent review of what some call the VOI scam click here.

Tom Emerick is the President of Emerick Consulting, LLC, and Partner and Chief Strategy Officer with Laurus Strategies, a Chicago-based consulting firm, and co-founder of Edison Health. Tom Emerick is the President of Emerick Consulting, LLC, and Partner and Chief Strategy Officer with Laurus Strategies, a Chicago-based consulting firm, and co-founder of Edison Health. 

Tom’s latest book, “An Illustrated Guide to Personal Health“, is now available on Amazon.

Categories: OIG Advisory Opinions

Accolade flying flag as patient advocates

Fri, 02/12/2016 - 20:00

I have spent years whining that no one is doing a good job helping people navigate through the maze of health care. And a survey out last week from my old firm Harris paid for by Accolade confirms that people need help. Doctors don’t and can’t do this. 71% of people said they trusted their doctors, but only 16% said their doctors had time to understand their life circumstances. Yet last summer a touted Silicon Valley startup called Better failed to make a go of a service doing just that.

Somehow Accolade seems to be threading this needle. They’ve raised more than $125m (including another $30m late last year beyond what I discuss in this interview). While they’re helping patients they’re charging their employers and insurers for the service. Late last summer I met Accolade’s EVP Amy Loftus. In this interview she explains what they do, and how it works.

Categories: OIG Advisory Opinions

The Radiology Report

Fri, 02/12/2016 - 07:47

“’Normal’ is one of the most powerful words a radiologist can use”: Curtis P. Langlotz MD PhD, Professor of Radiology, Stanford University

After I used “clinically correlate” thrice in a row in my report, the attending radiologist asked, “How would you feel if the referring clinician said on the requisition for the study “correlate with images”? When you ask them to clinically correlate, you’re reminding them to do their job.”

I had been a radiology resident for six months – too soon to master radiology but not too soon to master radiology’s bad habits. I had acquired several habits, tics to be precise. These tics included saying “seminal vesicles are unremarkable,” which I stated remorselessly on the CT of the abdomen in males, even if the clinical question was portal vein thrombosis, sending, I suspect, several young men to existential despair. But the tic that really got under my attending’s skin was “cannot exclude.”The attending was Curtis P. Langlotz, the author of The Radiology Report, a book about writing effective radiology reports.

Ubiquitous in clinical care, and sometimes parody, radiology reports are enigmatic. What’s most striking about radiology reports is their variability. Reports vary in length, tone, precision and frequency of disclaimers. Reports vary in strength of recommendations for further imaging.

One radiologist may say “small pancreatic cyst, recommend MRI to exclude neoplasm.”Another, aware that the patient may cross St. Peter’s gate sooner rather than later, may bury the findings in the bowels of the report, hoping the clinician will spots its irrelevancy. Yet another, eager to be non-judgmental,might say “small pancreatic cyst, likely benign, but MRI may be considered if clinically indicated,” which, Langlotz notes, is vacuous because with pancreatic cysts there’s nothing clinically the clinician can anchor that recommendation on.

Radiologists, conscripted to ail uncertainty in diagnostic medicine,have responded by introducing their own uncertainty.We remind physicians that “CT does not exclude ligamentous injury” on CT of the cervical spine which is negative for fracture. The pedagogic value of this disclaimer is lost by the second time it is read.

Why do we mention metaphysical truisms such as “sub segmental pulmonary embolism is not entirely excluded with absolute certainty?” This is part honesty and part disingenuity. Uncertainty is a fact of life. But radiologists know that clinicians know that no pathology can be excluded with absolute certainty. Stating this truism throws the ball back in their court, legally. The radiology report is a legal document.

The Radiology Report has been written in the way Langlotz hopes his colleagues write their reports. The book is short, readable, on point, and, importantly, the author takes a stand. He doesn’t hedge. Langlotz advocates standardized reporting, unapologetically. One may argue with the stand, and he knows that I often do(I argue with everything). But here is the point. Because Langlotz takes a stand, the conversation moves. The stand anchors the narrative.

Medical decision making is similar – you have to take a stand. Whileit is important to be right, it is better to be wrong than vague. Because when you’re wrong about a diagnosis, at least the clinicians know which diagnoses are wrong so that they can move to the next. By being vague, no one knows what should not be suspected. As I remind radiology residents before their call, “make a decision.”

Langlotz’s prescription for useless radiology reports is simple. Hedge less, be consistent and say “normal.” Like a date too polite to decline the second date, radiologists make all sorts of excuses for “normal.” Such as “liver is unremarkable.” Or “no CT evidence of abscess,” leaving one wondering whether they should wait for the non-CT evidence of abscess. Or, “no definite pulmonary embolism is seen” so that we’re all clear – radiologists don’t hear definite pulmonary emboli, let alone indefinite emboli.

Perhaps the most mysterious word in radiologist’s lexicon is “prominent” such as “pulmonary arteries are somewhat prominent.” Not even radiologists know what “prominent” really means. Is it that the pulmonary arteries are seen? Famous? Loud? Is Donald Trump “prominent”? Or is the structure big and we’re too gentlemanly to say so? Or is it another word that reflects our discomfort that normal and abnormal overlap?

Many radiology reports are baroque, clunky, and literal interpretations of the idiom “picture says a thousand words.”This is not just habit, but culture. I’ve seen many equate pith with laziness and verbiage with work ethic. Thus, “the liver demonstrates a normal size and contour, intact vasculature, and is devoid of a focal mass” has replaced “the liver is normal.” Bones are “osseous structures” rather than “bones.”“Osseous structures reveal mild degenerative disease in the lumbar spine” leaving oneshellacked –what a revelation. Why was it concealed?

If pith is underused, pith is also under appreciated. I once read a CT in a middle-aged man with abdominal pain. I said “no abnormalities in the solid viscera, hollow organs, bones or vessels.” I thought all bases were covered.Minutes later the referring clinician called. “You said the solid viscera were normal, but you didn’t say anything about the pancreas. We’re suspecting pancreatitis.” I amended the report: “I have looked at the pancreas and seminal vesicles and they are unremarkable.”

Radiologists see far more on cross sectional imaging, such as CT, than projectional 2 D imaging, such as chest radiographs. Thus, radiologists have become the chroniclers of age, as well as the finders of pathology. Everyone with a college degree, and nearly everyone without one, has “mild degenerative disease of the lumbar spine.” Show me a nonagenarian who doesn’t have “perivascular hypodensities suggestive of small vessel ischemia” and I’ll show you an incorrectly labelled CT head. And then there is the “somewhat atrophic uterus” – a finding which reassures the reader that the radiologist has a functioning visual cortex.

The greatest source of variability in radiology reports is agreeing about which of the epidemic of clinically insignificant findings should be mentioned in the report. I veer towards relevance. I’m happy to make a judgment call. Some veer towards completeness.

Langlotz doesn’t ask radiologists to rid disclaimers altogether. He identifies many situations where honesty about the imprecision is apt. For example, when a fracture is dubious, not slam dunk, on a radiograph,it is reasonable asking that findings be correlated with tenderness at the site. Context maketh a radiology report.

The Radiology Report covers more than smart reporting. There’s a nifty section about probabilities. And a hilarious chapter about speech recognition errors, my favorite – “right internal jugular coitus” when the radiologist said “right internal jugular cordis,” giving the erroneous impression that radiologists are watching Fifty Shades of Grey whilst dictating.

Langlotz has done an E.B. White for Radiology. I advise radiology residents to read The Radiology Report in their first year and after overnight call.  Non-radiologists should read this book, too, and hold reports to the standards he describes.

I credit Langlotz for my visceral dislike of “cannot exclude.”I also no longer say “seminal vesicles are unremarkable.” If you have nothing nice to say about someone’s seminal vesicles, say nothing at all.

Saurabh Jha is a radiologist based in Philadelphia and a contributing editor for THCB.

Categories: OIG Advisory Opinions

What To Make of the Senate Finance Committee’s Chronic Care Policy Options

Thu, 02/11/2016 - 20:31

This past December after eight months of formal work the Senate Finance Committee’s “Bipartisan Chronic Care Working Group” released for comment a 30-page memo outlining 23 policy options to improve chronic care quality, patient outcomes and cost efficiency. While the Committee is not endorsing any of the options identified members will likely not stray far from this list when they move to drafting legislative language next month at least in part because members insist the bill must be cost neutral. Committee members and staff should be applauded for their effort to date since both political parties have been disinterested in adding policies to improve the Medicare program. (Last year’s MACRA bill was largely unpaid for and aptly described by Henry Aaron in the New England Journal of Medicine as a log rolling exercise.) On balance, the Committee’s effort should leave Medicare stakeholders cautiously hopeful. While some of the proposed options are obvious and incrementally beneficial, others might aid in innovating care delivery and in advancing CMS’s efforts to improve quality and value payment.

The Obvious

Several proposed options are obvious in that they are long over due. The Committee proposes generally to improve the integration of care for individuals with a chronic disease combined with a behavioral health disorder. This proposal, possibly more than any other, could not be more welcomed. Behavioral health disorders in combination or not with chronic disease or another chronic disease are vastly under-diagnosed and under-treated. The Committee would be well served if members explored lifting billing restrictions that prohibit qualified non-physicians from treating beneficiaries with behavioral conditions. For example, there are limitations on clinical psychologists, clinical social workers and medical family therapists who are qualified but excluded from billing under the new chronic care management (CCM) code, evaluation and management codes and Health Behavior Assessment and Intervention codes. This is particularly problematic when you consider both the prevalence of behavioral health disorders and the shortage of trained behavioral health professionals.

The Committee proposes to expand telehealth services in four ways: waiving the originating site requirement for at risk ACOs; permitting MA plans to include telehealth in their annual bid amount; and, expanding its use to encourage home hemodialysis and the more timely diagnosis of stroke. The option concerning ACOs does not go far enough. There is substantial Medicaid, Veteran’s Administration, Indian Health Service and commercial plan evidence, despite the Congressional Budget Office’s (CBO’s) contrary view, telehealth and remote monitoring services are cost efficient. Also, this proposal as currently conceived would only help five percent of ACOs, or the 22 out of 434 that are currently in an at risk track. MA plans, for example Humana, have already begun using telehealth services formally or not just through the use of any rebate dollars. Regardless, adding telehealth services to MA coverage will only add to the already considerable number of ACO program disadvantages compared to MA. (As a related aside, the inequity between these two programs certainly helps explain why providers are fleeing to MA. Nearly 60 percent of 2016 MA plan growth is attributable to provider or PSO plans.) Allowing home hemodialysis patients to receive their monthly clinical visit via telehealth would, as the Committee notes, encourage more than the 10 percent of ESRD patients that currently receive dialysis at home. The policy would also improve patient independence, quality of life and reduce beneficiary exposure to iatrogenic harm. Expanding the use of telehealth to treat stoke cannot be more welcomed particularly when you consider the woefully low rates, at less than five percent, of tPA administration to treat ischemic stroke and the profound racial disparities in stroke care.

Two Committee options concern beneficiary out of pocket expenses. Both are welcomed. The Committee proposes to waive the current $8 CCM copay and allow at risk ACOs the option to waive beneficiary cost sharing. The CCM copay has been widely criticized and partially explains the slow uptake to date in provider use of the CCM code. While helpful, the option to waive some or all of an at risk ACO beneficiary’s cost sharing, again, does not go far enough. Considering the substantial problem of unstable assignment in the ACO program, offering copay waivers help insure beneficiaries remain assigned since they would more routinely seek care without having to decide whether care is essential or not and/or avoid higher intensity care particularly for beneficiaries who cannot afford first dollar Medigap coverage. This is the least the Committee can do.

ACO and MA Policy Options

There are five policy options concerning the ACO and MA programs that should be considered in relation to one another since these two programs interact or compete. The Committee proposes to “clarify” an ACO’s ability to offer social and transportation services without reimbursement. The Committee also proposes to expand the number of MA supplemental benefits to improve chronic care treatment. Considered in tandem once again ACOs are left disadvantaged. For ACOs innovation becomes at best an upfront expense while for MA plans, rebate dollars could be used to provide care from an expanded list, of an already extensive number, of supplemental benefits.

The Committee is considering allowing all individuals with ESRD the option of enrolling in an MA plan and requiring MA plans to offer the hospice Part A benefit. Currently individuals under 65 with ESRD are ineligible to enroll in MA with two exceptions and beneficiaries in Medicare fee for service (FFS) that are subsequently diagnosed with ESRD cannot enroll. Concerning hospice, the Committee is likely following MedPAC’s 2014 recommendation. Including hospice in MA, MedPAC argued, would promote integrated, coordinated care and make it more feasible for plans to offer concurrent curative and palliative care. How specifically ESRD and hospice care is integrated or further integrated in MA is important. For example, hospice access, beneficiary costs and quality under MA should at least comparable to fee for service hospice care. This point aside, since ACOs already offer ESRD and hospice care to all Medicare beneficiaries so too should MA plans.

Lastly, the Committee is proposing to give Track 1 ACOs the choice of whether their beneficiaries be assigned prospectively or retrospectively. Prospective assignment, already provided in the Pioneer and Next Generation demonstrations and in Track 3, allows ACOs to manage a less unstable patient population. The Committee states further ACOs that choose prospective assignment “should receive an upfront collective payment.” Providers choose Track 1 specifically to avoid an “upfront collective” or capitated payment. At first blush this proposal appears to make little sense. However, the Committee may have stumbled onto something. One of the primary criticisms of the ACO program is that it is a pay for performance model designed simply to lower spending. Since ACO providers are still paid FFS they have no incentive or ability to innovate to reduce costs by offering non-FFS reimbursed services. If Track 1 ACOs were allowed to choose prospective assignment in their second or third year or allowed to manage a subset of prospectively assigned beneficiaries under an “upfront collective payment” they would then be able to offer more widely skilled nursing, home health and other services CMS has been unwilling to allow, the same array of MA supplemental services and other or additional long term services and supports. Allowing Track 1s the opportunity to take a more incremental step toward downside risk might remedy the current stand off between CMS and the provider community that, as noted above, has led to limited industry interest in signing ACO risk sharing contracts.

Quality Measures

The Committee proposes CMS develop a laundry list of quality measures to improve chronic disease care that includes measures for patient engagement, care planning and shared decision making. Problems with the current state of quality measurement are well recognized. For example, if better quality lowers costs, the ACO quality measure set is a failure. In the 2014 performance year, out of the 60 ACOs that earned quality scores at or above 90 percent only 22 earned shared savings. Instead of identifying what measures or more measures there would be benefit if the Committee encouraged how measures are developed. As Michael Porter has argued, value or quality in health care should be measured by calculating the outcome attained for a specific condition (the numerator) over the total costs of a full cycle of care (the denominator). In addition, the Committee may want to consider how measures are reported. They should be reported at the group not individual level to encourage team work and care coordination. Providers should also be given the opportunity to develop self-reported quality measurement systems as has occurred in California. Providers would then have the option to report their self-reported measures, that are independently audited, or report via national reporting mechanisms such as the Group Practice Reporting Option (GPRO). This would in part encourage measurement ownership and enable providers to receive far more timely performance feedback. Provider performance should also be scored and rewarded based on the higher of two scores: quality performance attainment; or, quality performance improvement. This approach would in part level the playing field between providers in wealthier versus those in poorer communities.

Additional Proposed Options

The Committee is proposing several additional policy options Hill staffers would collectively term cats and dogs. The Committee is proposing: ways to improve the Hierarchical Condition Categories (HCC) risk adjustment model; proposing to expand the Independence at Home demonstration; extend Special Needs Plan program authorization; create two new chronic care management codes; improve Centers for Medicare and Medicaid Innovation (CMMI) transparency; expand beneficiary education; and, require two prescription drug use, not cost, studies.


Again, the Committee and staff deserve praise for their effort. Going forward, if the Committee holds to its cost neutral commitment members will need to convince the CBO telehealth services are substitutive, not duplicative. The Committee faces the same possible problem or limitation in creating new chronic care management codes and expanding or extending Medicare programming. It too is an election year and the bill currently has no comparative effort underway in the House. Hurdles or headwinds aside, one is left to wonder about other chronic care policy options not included in the memo. To name one it is beyond understanding how the Committee, along with CMS, continue to ignore the oral health of Medicare beneficiaries. Medicare has never covered routine oral/dental care despite the widespread prevalence of oral health disease and edentulism and, per the CDC, “profound” oral health disparities particularly when research shows treating periodontal disease among individuals with type 2 diabetes for example is associated with lower total health care costs.

David Introcaso is a healthcare policy consultant based in Washington DC. David’s acute care experience is via DC General Hospital and in post acute via in part his work with National Hospice and Palliative Care Organization, he consulted with a wide array of clients including the American Heart Association and the American Public Health Association and has taught as an adjunct at the University of Chicago and George Washington University. Over the past four years David has interviewed over 90 health care experts in producing independently a health care policy podcast  

Categories: OIG Advisory Opinions

Blog Notes

Thu, 02/11/2016 - 19:00

  • You can sign up for e-mail updates here.
  • Register for THCB here. You’ll need to register to comment.
  • If you do not receive a confirmation e-mail, drop us a note and we’ll set you up with access.
  • To submit a blog, e-mail us. Spend some time on the site before submitting.  THCB covers medicine, healthcare, technology and the business of the above.
  • If you’re interested in becoming a corporate supporter, you can email us for details or set up a call.
  • Some good news: we’re installing a new WordPress caching system. Pages should serve noticeably faster. Comments should load and go through faster and site search should (theoretically) work better. We’ll be fine-tuning things, but for the time being if you’re visiting THCB on your iPhone or Android device, you’ll want to refresh frequently to make sure you’re getting the most recent content.
  • An update:  Things appear to be humming along fairly smoothly. We’ve had a few reports of people having trouble with the comments system. If have problems, let us know. Send us a brief description of your problem. Be sure to include your browser type and o.s. details. You can also send us the text of your comment and we’ll post it for you.

Categories: OIG Advisory Opinions

Health 2.0 Unveils “10 Year Global Retrospective”

Thu, 02/11/2016 - 17:50

Health 2.0 announced today its  “10 Year Global Retrospective”, a platform to recognize outstanding achievements in health tech over the past ten years.

For nearly a decade, Health 2.0 has served as the preeminent thought-leader in the health tech sector and showcased and connected with thousands of technologies, companies, innovators, and patient-activists through an array of events and conferences, challenges, code-a-thons, and more. Since its first conference in 2007, Health 2.0 has grown into a global movement with over 100,000 entrepreneurs, developers, and healthcare stakeholders, and 110+ chapters on six continents.

In recognition of its 10th year, Health 2.0 will honor the superstars of the health tech community over the past decade through the global retrospective, a platform which will poll the collective insight of its vast network of health tech stakeholders who will nominate and vote for the top influencers in four categories. The winners will be showcased at Health 2.0′s 10th Annual Fall Conference in September in Santa Clara, CA.

The four categories open for nominations:

Industry Leaders (non-patients)
Patient Activists
Technology Companies
Health Care Organizations

Open nominations begin February 11th, 2016 and will close April 15th, 2016. Any person, company, or organization can be nominated and need not have appeared on the Health 2.0 stage to qualify. Each individual may nominate and vote only once and must nominate a minimum of two per category, and no more than ten for each category. All nominations are submitted anonymously.

What Happens Next?
After open nominations close on April 15th, they will be reviewed by an expert panel (to be announced soon!). Health 2.0 will announce the top ten nominees in each category on May 9th, at which time a second round of voting will open. Voting will remain open for each category for one week:

May 9 – 15, 2016:  Industry Leaders (non-patients)
May 16 – 22, 2016:  Patient Activists
May 23 – 29, 2016:  Tech Companies
May 30 – June 5, 2016:  Health Care Organizations

Winners will be announced June 27th and the top three finalists from each category will be invited on stage at the 10th Annual Health 2.0 Conference in Santa Clara, September 25-28, 2016.

Please Nominate, Vote and Share this Link!

Deepa is the Operations & Marketing Manager at Health 2.0

Categories: OIG Advisory Opinions

Precision Medicine is Taking Too Long and Here’s Why

Wed, 02/10/2016 - 23:42

We have been talking about Precision Medicine for a long time now but so far we are still in the infancy of using genetics to impact medical decision making. The human genome was sequenced in 2003,with the promise of rapid medical advances and genetically tailored treatments.  However, development and adoption of these treatments has been slow. Today with the advent of large cohorts, and in particular, the construction of the US Government’s Precision Medicine Cohort,[1] conditions are being set up for precision medicine to flourish.  In the PMI infographic,it states three reasons for ‘Why now?’ – sequencing of the human genome, improved technologies for biomedical analysis, and new tools for using large data sets. While I agree this is progress, I believe there area few fundamental other areas to be tackled in order to really get to the promise of precision medicine.

  1. The concept of protocols is designed for mass production not mass personalization

Medicine is practiced using protocols and documented in EHRs. When written down they can look like a cook book or a choose-your-own-adventure story book. The intent is to codify medical knowledge into a guide that can be consistently used by all physicians to obtain the ideal outcome. But as a result of strict adherence to medical practice standards, they inherently choose paths that are well defined based on the assumption that most people are similar in their response to treatments. So over time the protocol is enhanced to suggest which decision is the right one to make with a given patient and a protocol will more often than not be ‘anti-precision,’ just in the same way that a factory is designed to make one size of jeans at a time rather than make a custom set of jeans for each customer visiting the store.

Protocols are analogous to laws. There are many parties, normally ones selling interventions or diagnostics, interested in wrestling for the control of a part of the protocol in order to optimize their own benefits. So like the laws, the number of places where a protocol can be diverged is dependent on the body that is building the protocol being able to deal with the divergent inputs from the many interested parties providing their evidence of why the protocol should include their suggested adjustment to improve patient benefit. There is nothing nefarious in this situation, as a better protocol will lead to a better set of patient options. But the model is just much more conducive to a small set of interventions and a small set of conditions being reviewed slowly to approve the changes in major paths than a precision model.

This paradigm of the protocol needs a major refresh to accomplish the goal of making a transition to a new world of precision medicine. For example,in HER-2 positive breast cancer patients we have learned to use Herceptin because it is a well understood variant and treatable because of the biology of the drug and cancer cells. But the Herceptin test is only a small part of cancer diagnostics and precision treatment options. There are 20 or possibly hundreds more key targets to test with increasing combinations looking more like signatures and combination therapies that are not as binary as a single test.As we start to tune-up the number of potential interventions and number of potential variations among patients, we are getting into the problem that having a simple decision tree quickly breaks down into complex graphs that may be impossible to document as a protocol. Furthermore, the body of evidence needed to support each decision becomes limited relative to published statistical ‘proof’ standards we have historically had in order to pick which path to take.

So – in short – if we want to have personalized medicine we need to figure out how to make a quantum jump that some industries have made such as media – from mass production – newspapers and books, to mass personalization –in the context of the current structure of regulatory science and ethics. We need to invest in more people with regulatory science and medical ethics to sort this out to figure out the right model since getting to bigger data only exacerbates this issue.

  1. Economic realities of precision options

While there is a clear opportunity to provide a better service through mass personalization, there are some big financial issues to resolve for any first mover offering an intervention in the space. The current economic model for drug development still requires a drug to have a return on investment in the range of billions of dollars. This means that creating diagnostics that can significantly limit the potential addressable market are still economically disadvantageous. Now it is fair to say that it is unethical to not know the precise conditions when a drug will and won’t work. But for as long as it is impractical and difficult to answer to the question of precisely when a drug will not work, there are incentives to not invest heavily in seeking findings in this area without a regulatory group requiring it with clear guidelines and associated incentives or a ‘disruptive’ set of players in the market.

Currently,no one has found a way to disrupt the current pharma business model by identifying when drugs will not work and paying for that research with a diagnostic that is reimbursed to do so. So if I can sell tests that determine which 3 of 10 people will not benefit from a drug through a precision medicine diagnostic– in theory it is an ‘ounce of prevention’ for waste and should obtain the cost benefits of waste avoidance. But no break-out story about the AirBnB or Uber drug diagnostics company cutting down the cost of drugs in this way has been established. It hasn’t really happened yet. If such a business model were to become quickly dominant like these consumer disruptions, then drug development would need to assume that when there is variation in response, that it will be rapidly identified by such groups and capitalized on by the third party and not the drug maker. But that is not yet the current world we live in. Maybe it is going to change in a value-based care world where the total cost of care can create the opportunity to add this new ‘diagnostic’ player, but so far value-based care is not deeply penetrated enough into the overall model of US or global care. For now it takes a new reimbursement code to be able to introduce such tests and the value is hard to justify. My guess is that while the research could be done, the valuation of the tests are not sufficient to justify the kind of scale investment needed to identify the variants and the organizations with the capacity to do so are better suited to create new interventions.

  1. Big Data technology companies involved in precision medicine aren’t medical device companies yet

Currently we have a number of technology companies that are ‘using Big Data’ to be able to support decisions. A big data cognitive engine is needed to break through the protocol driven system to formulate a model driven system where the decision path is more opaque but technology can still provide the right recommendations based on the body of available collected genetic and clinical evidence. As of today,systems like this haven’t been built and approved for broad medical use yet.One of the reasons these systems don’t exist yet is because such a system is a medical device and should comply with the same rules.We have seen the sorts of trouble that have occurred from the disposition of “medical device” being applied to Silicon Valley generated innovations.The regulatory world may need to catch-up to the capabilities and model of the newer technology, and the newer technologies will also need to admit that they need to modify their operating model to acquire FDA approvals to be trustable and involved in the liability of medical decision making.


While my view of the situation is sobering, I am optimistic about the transition from current medicine into a precision medicine world. It seems that most of the barriers have fallen from a technical point of view. We just need to work on the areas that are the key drivers. Some of these will get solved by market forces but others are still in the hands of regulators and leaders of the medical community managing the creation and diffusion of protocols. Big data businesses will get smart and involved in approving their systems as components of medical devices or they will not be players.New players will soonemerge that focus on reducing the waste in prescribing medicine that doesn’t work. Physicians will figure out within their societies how to transform their operating models including protocols and compensation structures to enable precision medicine. Let’s get this done.

[1] (

Dan Housman is CTO at ConvergeHEALTH by Deloitte

Categories: OIG Advisory Opinions

Shining the Light on Cancer Surgery Volume

Wed, 02/10/2016 - 21:19

New data just released on cancer surgery volume in California hospitals advance an important and complex discussion about how the frequency with which a cancer surgery is performed at a hospital might influence patient, care team and hospital decisions. An effort funded by the California HealthCare Foundation has recently made these data available for the first time for 341 California hospitals on Having these data readily available opens the door to important inquiries the hospital community is investigating closely. Transparency about cancer surgery volume is, however, just one step toward better understanding and practice. More data and close deliberation are needed, and we must take caution to avoid premature conclusions with insufficient evidence.

Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency and location of surgeries for 11 types of cancer.The report reveals that many hospitals performed certain cancer surgeries only once or twice in 2014 and that many cancer patients were within 50 miles of another hospital performing their needed surgery with greater frequency. The report is spurring productive discussion.  However,as it is descriptive of cancer surgery volume alone and does not capture patient outcome, it calls on the hospital community to gather more evidence to inform decision-making. As conveners and catalysts for hospital improvement, the California Hospital Association and the Hospital Quality Institute, along with other leaders, are capturing this opportunity to advance the research and dialogue on cancer surgery volume.

Healthcare professionals have long discussed the relationship between surgery volume and patient outcomes, along with a myriad of other influencing factors.Is there a threshold defining when a hospital is performing so few of a certain cancer surgery that patients should instead be sent to the closest hospital performing the surgery at a higher volume? There isn’t – yet. Should there be such guidelines? Ideally, but it’s complicated.More questions need to be asked to find the answers.Safety in Numbers gives us some direction on what questions to ask and shines a light on variation in cancer surgery volume not previously or widely understood.

As health care systems and data collection become more sophisticated with better electronic medical records and other advancements, we can look forward to greater insight with increasingly precise data. Many factors influencehow surgeries are coded and counted, impacting how the data are interpreted. Hospitals are looking at surgery volume and patient outcome data closely and considering what changes may be needed for patient care options. For example, CHA is collaborating with cancer registries, which are providing valuable new data to inform analysis.HQI is working closely with the practitioners and executives at hospitals throughout CA to examine variables highlighted in the report.  CHA, HQI and other leaders, such as the American College of Surgeons, have an on-going dialogue and research efforts about surgery volume and patient outcomes. With more literature and data will come more sophistication in our ability to interpret what cancer surgery volume tells us.

Other critical factors to consider include physician competency and patient demographics. While practice may generally make perfect, frequencies is just one of a number of variables correlating with skill. Hospitals have on-going training and credentialing processes and review the performance and competency of both surgeons and hospital staff.The patient and family voice is also an essential perspective to listen to and consider in exploring recommendation about cancer surgery volume thresholds. Socio-economic and geographic considerations often influence where a patient can access surgery and where loved ones can be present to help. A hospital that is 50 or 100 miles away, requiring more travel and perhaps lodging expenses for family, can create a hardship versus the ease of a nearby facility. These factors have to be taken into account when assessing patients’ best options.

A few health care systems are introducing surgery volume thresholds, such as Johns Hopkins. It is noteworthy that systems like Johns Hopkins are concentrated closer together in urban areas. Many health systems in California, like many parts of the country, face large rural areas with great distances between facilities. These geographic factors will also influence what guidelines might be suitable for different health care systems. It is important to keep in mind that what may work best in one health care system may not be best in another, just as what is best for one patient may not be for another.

HQI is supporting and working with the American College of Surgeons and other professional associations to improve quality of care and assess surgical safety, one of HQI’s top priorities. As key players are discussing this issue in greater detail today than in the past, we see significant new potential for a thoughtful, constructive process. We are at the start of a long journey toward finding the best approaches for addressing cancer surgery volume variation. The release of this new data is an important step on this journey.

Julianne Morath, RN MS, CPPS, is President and CEO of the Hospital Quality Institute and David Perrott, MD, DDS, MBA, FACS,is Senior Vice President and Chief Medical Officer for the California Hospital Association

Categories: OIG Advisory Opinions

Seth Sternberg talks about Honor

Wed, 02/10/2016 - 19:46

Seth Sternberg was a founder at instant message service Meebo, which was acquired by Google in 2012, and like many tech guys he’s next decided to try to change the health care experience. But unlike many others the aspect he wanted to change was the in home caregiving market, following a bad experience with his own mother. Honor came out from under wraps last year, raised $20m, and is currently operating in Los Angeles and San Francisco. It’s not only a market place where you can hire caregivers for a loved one, but it also allows the client, whether they be the person receiving the care or their loved one–that daughter out of town–to manage the process end to end including booking and paying, and allows the caregiver to report on what they are doing, and follow a careplan.

But beyond that Sternberg is on a mission to “professionalize” the caregivers by not only increasing their pay, but accurately matching them to client needs, and increasing their control over their own situation. To that end Honor recently backed off the Uber independent contractor model and made its caregivers full employees (with stock options!). Very interesting guy with an interesting model. Here’s the interview:

Categories: OIG Advisory Opinions

It’s Time to Talk about Cancer Surgery Volume

Wed, 02/10/2016 - 07:07

Twenty years ago as a newly trained oncologist, I faced the same challenge that many cancer patients and their families do as they try to figure out where to turn when my mother was diagnosed with ductal carcinoma in situ– or pre breast cancer.  Her surgeon, who had come highly recommended by her family doctor,told her she needed to have a lymph node dissection, which can result in lifelong disability due to lymphedema or swelling of the arm.  As an oncologist, I knew it was not recommended for ductal carcinoma in situ, but she resisted my suggestion to get a second opinion. Despite the fact that I—her daughter—am an oncologist, her first thought was, “I can’t go against what my family doctor told me to do.”

It is still not part of our general culture to question physicians and, in a sense, to discuss health care options. Many patients are shell shocked by a cancer diagnosis and don’t think beyond what they are immediately told to do or where they are told to go for treatment. Some highly motivated patients dig deeper to research their options for cancer treatment, but these motivated patients are still a minority.

California is now leading the way in publically reporting cancer surgery volume to make it easier for patients, as well as health care professionals, to access and compare information on the frequency of surgeries at different hospitals. I participated in the Advisory Group, informing an effort funded by the California HealthCare Foundation,to make cancer surgery volume data available for the first time for 341 California hospitals on Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency of surgeries by hospital for 11 types of cancer for which there is an association between low hospital volume of surgeries and increased mortality and complications.

While more research is needed to analyze and understand the linkage, this new access point facilitates conversation between patients and doctors as well as between health plans and hospitals. The new data identifies important areas to research and helps health plans to enter into dialogue with hospitals where low volume surgeries occur.

The idea of establishing thresholds — or minimum frequencies — for cancer surgeries is complex, but most of us can agree that a red flag goes up when a hospital is only performing a surgery once or twice a year. It is important for hospital administrators to ask why this occurs and consider referring patients to higher volume facilities. In some cases, an emergency surgery took place, but Safety in Numbers illustrates that low volume cancer surgeries are much more prevalent than many of us realized.

In fact, almost 75% of California hospitals performed surgery for one of the 11 types of cancer only one or two times in 2014.  Most patients—between 60% and 81% depending on the cancer type—who had surgery at a hospital performing a low number of those surgeries in 2014 were within 50 miles of a hospital performing higher volumes.

Anthem health plans,in concert with the Blue Cross Blue Shield Association, have developed Centers of Excellence for rare and complex cancers. Anthem health plansassign case managers to patients with serious medical conditions to help those facing tough decisions find a qualified hospital specializing in their condition.The goal of Anthem health plans is to direct members to the Centers of Excellence, made available online. We already encourage consumers to have surgery at facilities experienced with their specialized condition and our case managers are trained in discussing the Centers for Excellence and assisting members in getting second opinions.

A key challenge is getting information into the hands of consumers quickly enough – they need to understand their options when they are making the decision about where to have surgery. Members often engage with case managers after surgery has occurred and as they continue in their treatment. As we explore ways to get important information about cancer treatment options upstream to consumers, efforts like this by the California HealthCare Foundation can help raise awareness.

Safety in Numbers provides both the evidence and the data to start including volume as a criteria in our Centers of Excellence research. While the centers have focused more broadly on different types of cancer, we can use these data as a basis and may start to focus on the outcome-surgery volume link. It is and will, however, continue to be difficult to identify specific thresholds as a criteria to determine treatment options. There are many factors contributing to patients’ options, such as the distance they may need to travel to different hospitals – though our health plans do cover such travel expenses.

While Safety in Numbers raises important questions about whether the medical community should establish thresholds for complex cancer surgeries, health plans can look for ways to move the dialogue with hospitals, physicians and patients. We must also look at what else high performing teams are doing that other hospitals can replicate, as there will always be many factors influencing surgery outcomes. It makes sense to avoid surgery altogether when possible.  For example, combined treatment with chemotherapy and radiation has the same long-term survival as surgery for esophageal cancer. As we move to make available data on surgical outcomes, we need to make sure patients have the full range of treatment options presented to them so that they can make the best choice given their own life circumstances and preferences.

As research and understanding about surgery volume continues, it would be helpful for health plans to have access to measures linking surgery volumes to outcomes that are established by medical associations, such as the American College of Surgeons.Continuing research on surgery volume-outcome linkages, leveraging the new data now available on cancer surgery volume in California, and promoting dialogue on this issue will, ultimately, benefit patients and health care systems.

Jennifer Malin, MD, PhD, is Staff Vice President, Clinical Strategy at Anthem, Inc.

Categories: OIG Advisory Opinions

Give up Your Data to Cure Disease? Not so Fast!

Tue, 02/09/2016 - 10:52

This weekend the NYTimes published an editorial titled Give Up Your Data to Cure Disease. When we will stop seeing mindless memes and tropes that cures and innovation require the destruction of the most important human and civil right in Democracies, the right to privacy? In practical terms privacy means the right of control over personal information, with rare exceptions like saving a life.

Why aren’t government and industry interested in win-win solutions?  Privacy and research for cures are not mutually exclusive.

How is it that government and the healthcare industry have zero comprehension that the right to determine uses of personal information is fundamental to the practice of Medicine, and an absolute requirement for trust between two people?

Why do the data broker and healthcare industries have so little interest in computer science and great technologies that enable research without compromising privacy?

Today healthcare “innovation” means using technology for spying, collecting, and selling intimate data about our minds and bodies.

This global business model exploits and harms the population of every nation.  Today no nation has a map that tracks the millions of hidden data bases where health information is collected and used, inaccessible and unaccountable to us.  How can we weigh risks when we don’t know where our data are held or how data are used? See .

Medicine was always based on a relationship of two, a doctor and patient. Doctors earn trust by protecting patients’ sensitive information, so patients will share intimacies and speak freely about symptoms. How can anyone trust millions of companies holding data bases and selling personal health data? The world’s largest data information, services, and technology  company has longitudinal profiles of 500 million people. The corporation’s IPO describes buying and trading health data with 100,000 health data suppliers covering 780,000 daily health data feeds.

Current commercial “innovation” targets eliminating human and civil rights to privacy—by design. Inevitably patient trust in health professionals, hospitals, research, technology, and government is destroyed. So millions of patients act to protect privacy by hiding health information, and delaying or avoiding treatment for serious conditions like cancer, depression, and sexually transmitted diseases. Do we want electronic health records systems that drive patients away from effective treatment?

Instead commercial innovation could use technology to ensure and protect human and civil rights, and put people in charge of their data. Millions of patients will agree to enabling research queries, ensuring research they care about and privacy. This ‘New Deal on Data’ model will be equally profitable for major corporations, while benefitting individuals and supporting Democracy. See:

Current technology products and IT services were designed for totalitarian government and corporate surveillance, exploiting and controlling humans by destroying fundamental human and civil rights to determine who can use personal information. Surveillance enables 1) deeper more intrusive data collection and aggregation, 2) deeper, more extensive individual profiling for hidden discrimination and data sales , 3) costly new services, treatment, and products that grant corporations and governments ‘rights’ more power than the rights of humans.

We can choose technology to strengthen individual autonomy and agency, which is also a revenue-generating engine to support Democratic governments, institutions, and corporations. Shouldn’t we choose technology that ensures and protects human rights and values, and enables massive research with patient consent?

Why do surveillance technologies used by enemies of the state have any place in the modern practice of Medicine and healthcare? Like Democracy, the purpose of Medicine and healthcare systems is to serve individuals and respect human and civil rights.

The current business model of the Internet and the world’s largest tech corporations is the collection, aggregation, and exploitation of personally identifiable information. But the downside for humans ranges from preventing trust in relationships, to secret discrimination, to imprisonment and death. Entrenched, global monopolies don’t want change, but their business models must be replaced. And people everywhere will demand it.

Governments and businesses may actually have to treat people like people, not like data on the IoT. 90% of data is human data. Technology systems that serve human needs for privacy will be just as lucrative as current exploitive data surveillance and collection technologies, but everyone wins.

Are calls for “cures” and “innovation” that use surveillance technology to collect intimate personal health information being disguised as sheep?

Categories: OIG Advisory Opinions

Aver: Analytics for Care Episodes –Nick Augustinos interview

Mon, 02/08/2016 - 14:16

Nick Augustinos was at Healtheon (later WebMD) in the early days, then at Carescience with David Brailer, and later was senior in the health care teams at Cisco and Cardinal. Given Nick isn’t as young as some health tech startup guys and did OK back in the day, you might wonder why he’d leave the cushy corporate world and take on the supervising adult role at a startup.

But he just did, with Aver–an analytics company focusing on incorporating incentives and quality improvement in bundled care. Last month it raised $13.6m in a series B and I had a quick chat with Nick to find out what Aver was up to.

Categories: OIG Advisory Opinions

The Science of Medicine: Zika and Correlation vs. Causation

Mon, 02/08/2016 - 05:18

Last week I told you of my admiration for Dr. Mona Hanna-Attisha, the Michigan pediatrician and epidemiologist whose strong research and advocacy was able to finally bring a shining light to the problem of lead in the water supply of Flint.

Continuing with a theme, I now bring you the story of Dr. Adriana Melo of Campina Grande, Brazil.

Dr. Melo is an OB-GYN who subspecializes in Maternal-Fetal Medicine (MFM), the branch of obstetrics that deals with high-risk pregnancies.

She lives and works in northeast Brazil, which is less populous and more economically challenged than the southern, more well-known parts of the country (including Rio de Janeiro and Sao Paulo).

Dr. Melo noted an uptick in the number of fetuses with small heads on ultrasound — which is the main tool used by MFM doctors to diagnose babies in utero.

How much of an uptick? A rough look at the statistics shows ONE HUNDRED times the ‘normal’ rate of babies born with microcephaly, the medical name for the condition.

Dr. Melo had a suspicion that the mothers giving birth to these babies all had a common trait: they’d all told her that they’d had the characteristic rash associated with the mosquito-borne Zika virus.

When she tested the mothers for evidence of the Zika virus in their blood, the tests were negative. Not deterred, she convinced public health authorities to test the amniotic fluid of mothers carrying microcephalic fetuses. And indeed a strong correlation was found between exposure to Zika and microcephaly.

It’s this story of a doctor in a somewhat out-of-the-way place using her clinical insight to ‘prove’ a correlation which I find inspiring.

Dr. Melo could have been content to merely diagnose and treat these poor mothers and babies, perhaps simply ‘reporting up’ her findings on the increase in microcephaly. Instead, she decided to push against the inertia of daily medical practice because what she was seeing really bothered her — and as a mother of young children herself, she felt the urge to get to the bottom of the new trend.

If you follow health news, you no doubt have heard a lot about the Zika virus in the last few weeks, including warnings from both the CDC and the World Health Organization. As is often the case with warnings from these organizations, a certain amount of panic ensues — such as women in Latin America feeling that they’re being told not to get pregnant, for example.

I want to make it very clear that though there is a STRONG ASSOCIATION between the rise in cases of Zika in the tropics of the Western Hemisphere and a concurrent rise in babies born with microcephaly, we must remember: Correlation does not equal causation. The public health agencies issuing travel and birth control warnings, while sounding dire, are making best guesses for us all to minimize our chances of harm. But drowned out in the response is the fact that we don’t yet know for certain that Zika is the cause of microcephaly. That work is ongoing.

For example, many experts think something else may be the cause — perhaps the use of dangerous pesticides in Brazil (that are banned elsewhere). That also sounds plausible since pesticides are used to “control the mosquito vector.” It’s entirely possible that microcephaly is occurring because of a chemical effect.

For now, we must wait and hope that science can show us the true cause of the uptick in microcephaly.

I also think it’s important to remind ourselves of two things about Zika virus: We’ve known about it since the 1940s, when it was discovered in Africa — so though if feels new, it’s really not. Secondly, at least for non-pregnant people, it only appears to cause mild flu-like symptoms and be a self-limited illness (not more than a few days at most).

My advice: Better to save your anxiety for the never-ending Presidential race.

John Henning Schumann, MD, is President of the University of Oklahoma – Tulsa. He blogs at and is on Twitter: @GlassHospital.

Categories: OIG Advisory Opinions

Can the Exchanges Be Saved?

Sat, 02/06/2016 - 22:30

“The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” —William Arthur Ward

Looking confidently past the skeletons of drowned state and federal healthcare experiments, America’s health insurance exchanges set sail in January 2014. Disregarding the rough seas ahead, healthcare reform pundits and legislators applauded the Affordable Care Act’s signature public expansion vehicle as an impenetrable solution for achieving affordable coverage and competition.

Less than two years later, the exchanges are taking on water.

In November, United Healthcare lowered earnings projections, a move driven primarily by its hesitancy to commit to enrolling new exchange members until risks are better understood. While other insurers were quick to reassure investors that the public exchange market remains a viable means for organic growth, a low-pressure system of doubt is already building over the nascent public exchanges.

Initial enrollment projections for 2016 are fewer than 10 million members—about half of the 20 million target estimated by the Congressional Budget Office. In their rush to expand coverage to the uninsured and under insured, many public officials and industry neophytes failed to consult with those who have firsthand experience with the difficulties of underwriting those who are obtaining insurance for the first time.


Enrollment projections for 2016 are fewer than 10 million members—about half the Congressional Budget Office target of 20 million.
The rush to participate in public exchanges has attracted inexperienced players seeking a piece of a $300 billion premium opportunity.
Investors want desperately to believe healthcare is ripe for transformational disruption.

Rush to Judgment

The rush to participate in public exchanges has launched a flotilla of inexperienced players all seeking to get a piece of what many have described as a $300 billion premium opportunity. The reassurance of a functional distribution system of consumer purchasing portals, reinsurance dollars to hedge against adverse selection and penalties for failure to purchase insurance seemed to signal a sure thing. Public exchanges would foster new competition, prune excessive insurer margins and eliminate self-serving industry practices that have left an ever expanding number of Americans uninsured—many of whom were working for small businesses that simply could not afford to cover employees.

It is indeed an irrational time. Consider Oscar Health Insurance, a commercial and public exchange insurer with a market cap exceeding $1.5 billion. While Oscar lost close to $30 million in 2014 and has only 40,000 members, it boasts a valuation multiple above the nation’s largest insurers. It seems that investors want desperately to believe that healthcare is ripe for transformational disruption—think self-service health apps that can capture the hearts and minds of millennials and Gen Xers.

While these are innovative, consumer-friendly solutions, most of their target consumers either don’t buy insurance or don’t consume many of the services that currently drive costs (e.g., specialty drugs or hospital inpatient services for chronic conditions and other illnesses endemic to older populations). The fact is, money and resources are pouring into this newly expanded market of potential insureds, yet many of them are sick or low-income people who are less likely to engage or adopt the technology—unless it comes with a cheap policy.

Ovid once said, “The man who has experienced shipwreck shudders even at a calm sea.” Indeed, national insurers who still bore the scars of past expansion experiments were nervous about the exchanges. They counseled caution and slow going, even as newcomers eagerly entered the marketplace, casting aside these warnings—and 20,000 pages of unread legislation.

Many were buoyed by reassurances from the U.S. Department of Health and Human Services that any losses arising from adverse selection and uneven enrollment would be reimbursed by the 3Rs—risk adjustment, reinsurance and risk corridors.

But they underestimated the complexities and unintended consequences associated with administering and enrolling an entire segment of our society that had not been participating in commercial or public health insurance systems. The actuarial results in 2014 were sobering—more than $250 billion in losses against a paltry $300 million in excess profits. As of November 2015, Health and Human Services can refund only 12% of the 2014 losses to underperforming plans. And an increasing number of new entrant co-op healthcare plans are in bankruptcy or in dire financial straits.

So what went wrong?

Affordability and Access

Both the federal and state-based exchanges were immediately riddled with administrative hassles and consumer access problems. The embarrassing miscues and failures of were ameliorated only when federal officials turned to industry-based specialists at Optum to assist them in repairing their flawed technology and process. In that same period of time, we have witnessed spectacular failures in more than half of the state-run exchanges.

We have also seen a marked increase in public exchange health premiums—in some cases well above the 10% increase benchmark that HHS established as “egregious.” These price increases discourage reenrollments. In fact, the largest public exchange participant, Anthem, recently reported an 8% decline in 2016 reenrollments. In a market driven by two simple axioms—affordability and access—many have failed.

One wonders if the architects of the S.S. Affordable Care Act have ever left shore. Few seem to understand traditional commercial underwriting or the volatility wrought by such a highly regulated file-and-approve rating process. File-and-approve pricing requires insurers to submit rates for approval well ahead of effective dates of coverage—often with little visibility of the risk attributable to the members currently enrolled.

Under the law, the actual time lag between when a carrier sets an annual premium for a specific product and the period in which claims reveal the true underlying risk is hopelessly out of step. Exchange insurers have essentially less than one month to assess the risk profile for their Jan. 1, 2015, enrollees before submitting 2016 rates for approval. To quote one insurance CEO, “ACA regs put you two years out of sync with the reality of the economics of the business.”

Insurers must now either build in excessive margins to hedge against adverse selection, which leads to less competitive premiums, or take the risk and hope the reinsurance pools and risk corridors will make them whole.

Carolina Journal Online recently reported: “Health insurers across the country are experiencing massive losses despite healthy inflows of federal cash. The scope of the problem varies by state. But the problem is essentially national. It stems from the very architecture of the ACA, which offers too heavy a subsidy for some customers and then attempts to spread that cost over too narrow a set of other ones.”

As if the legislation is not difficult enough to manage, Health and Human Services is violating basic rules of risk selection for the sake of garnering maximum membership. The agency is allowing applicants to apply after open enrollment periods have concluded, which is tantamount to allowing people with houses on fire to purchase property coverage. Insurers have determined that the loss ratio on “special enrollment” membership is a full 15 points worse than the traditional open enrollment risk pools.

Jumping Financial Guardrails

Take, for example, the state of New York. When it established its minimum loss ratio of 75% for small business, it promised to use the excesses of those insurers that achieved lower loss ratios to reimburse insurers who lost money. Aside from the obvious misguided incentives this created for some insurers to under-price, it quickly resulted in few carriers actually experiencing medical loss ratios below 75%. The state quickly determined there would not be enough excess premiums available to compensate those who experienced higher loss ratios—leading to industry exits and higher rate increases.

Future attempts to cover New York’s uninsured occurred through Healthy NY, which offers comprehensive health insurance to small businesses. But even though it was supported by risk corridors and risk reimbursement, Healthy NY failed to offset losses incurred by underperforming insurers. And in some cases, the losses did not come from bad risk selection.

The law also provides a misguided incentive for new entrants to compete without adequately resolving obvious shortcomings, such as inferior network discount contracts with providers, limited medical management and, in some cases, aggressive pricing to win new members. When these firms finally sobered to the fact they would not be made whole for losses, that there were no excess dollars available to pay them, these same insurers either failed or left the market.

The Affordable Care Act uses risk adjustment, risk corridors and reinsurance to help insurers weather the first few years of uncertain demand arising out of newly covered uninsureds. The risk corridor program, which expires in December 2016, is failing. According to one industry observer, “The legislation suggests that HHS will try to make these insurers whole, (yet) a conservative Congress is not likely to appropriate more dollars to prop up underperforming insurers. The result would be catastrophic, as it would prevent the natural selection of a free market from eliminating its poorest performers.”

The observer went on: “Despite administration claims that incoming payments from profitable insurers would cover losses from unprofitable ones, the risk corridor program shortfall exceeded $2.5 billion in 2014. Insurers with lower-than-anticipated claims owed about $360 million, and insurers with higher-than-anticipated claims requested about $2.9 billion from the program.”

Failed pricing is now manifesting itself in 2016 exchange pricing. Consider a sampling of the following states:

  • CareFirst of Maryland: 34% increase for its PPO plan, 27% for its HMO
  • North Carolina: 26% increase from Blues
  • Oregon: 25.6% increase from largest market share insurer
  • BCBS of Tennessee: 36.3% increase
  • Georgia: 19% average increase
  • Iowa: 43% increase
  • Kansas: The increase could be as high as 38%.

Adverse Selection Is Real

The Kaiser Foundation estimates that “65% of individuals expected to purchase health insurance through the Exchange, transition from being uninsured…. (More than) one third of individuals expected to enroll in the Exchange have gone more than two years without a checkup (37%), nearly two in five did not have a usual source of care (39%), and more than a quarter had no interaction with the healthcare delivery system during the year at all (29%). The findings on access barriers indicate … these Exchange enrollees may have a large pent-up need for medical care once they gain insurance. It will be important to monitor whether individuals who gain insurance coverage through the Exchanges continue to have difficulty accessing care and whether there are adequate primary care providers to address their healthcare needs.”

Despite federal and state reports that suggest there is an adequate demographic spread of young, middle-aged and older Americans accessing care, adverse selection will continue to reign supreme. It’s logical to assume those who sign up for care are more likely to consume it than those who choose to pay a penalty. With less than one quarter of the target uninsured population likely to sign up, a fiscal storm is brewing.

Beginning of the End?

The concerns over the viability of public exchanges are real and legitimate. Insurance underperformance, the government’s commitment to make losing parties whole, dramatic spikes in healthcare costs (such as those for specialty drugs) and the potential for Congress to repeal the Cadillac tax provision, which was expected to raise up to $120 billion over 10 years, are bringing to bear the full weight of the legislation. And we fear the ship is sinking.

As far as exchanges go, we could be in a temporary period of enrollment attrition and risk pool deterioration. And this expansion experiment may not be salvaged without more congressional funding and enabling intervention. If that is the case, Congressional Budget Office estimates of a $140 billion surplus in 10 years will be obliterated, and yet another entitlement program will further accelerate our deficit and rising public debt.

But the news is not all bad. Survival is possible on the public exchanges, but it will take stamina to weather early storms and execute across a wide range of stakeholders. Anyone taking risk must have the following:

  • A trusted brand that resonates with consumers
  • Access to capital to withstand the lower margins of heavily regulated public exchanges
  • The ability to serve as a nexus to aggregate lives
  • The ability to manage risk
  • A clinical footprint wide enough to serve a target population
  • The ability to change patient behavior.

But perhaps the most important attributes of anyone playing the exchange game are emotional intelligence and the ability to achieve a collaborative culture across stakeholders often working at cross purposes. Healthcare delivery is fundamentally changing, and this type of transformation requires a strong and united crew to succeed.

Michael Turpin is frequent speaker, writer and practicing benefits consultant across a 27 year career that spanned assignments in the US and in Europe. He served as the northeast regional CEO for United Healthcare and Oxford Health from 2005-2008 and is currently Executive Vice President for Benefits for the New York based broker, USI insurance Services. He blogs regularly at Usturpin’s Blog.

Categories: OIG Advisory Opinions

Interoperability Form and Function: Interview with Doug Fridsma

Sat, 02/06/2016 - 22:08

Leonard Kish talks to Douglas Fridsma, President and CEO at American Medical Informatics Association, about his work in the Office of the National Coordinator for Health Information Technology, or ONC, and the barriers to implementing MIPS in the most useful and transparent way. In order to communicate the data, of course, we’ll need informatics; but how will that work? And which comes first, policy or technology?

Leonard Kish: When you first began your studies in medical informatics, was there a sense that the field was a science?

Doug Fridsma: After working on the Standards of Interoperability Framework for the National Cancer Institute – which was essentially crowdsourced, I engaged government, research and other pharmaceutical companies and standards organizations to basically come up with what that standard should be – I had an opportunity to go out to the University of Arizona and ASU. Ted Shortliffe, who had been my mentor at Stanford, had just been appointed to be the Dean of the new medical school at the University of Arizona.

Fundamentally what physicians do is information management. The thought we had was, if we really wanted to change the way we use technology in medicine, then one of the biggest ways we can make an impact is to train medical students to engage in and to learn this information, then we can actually start to develop the physicians of the 21st Century.

It was a great opportunity to get in on the ground floor with a blank slate, so there could be there was a new effort to include informatics and information management into the training.

As I started working on developing the curriculum at ASU, we approached informatics from a new angle. If you want to teach someone about pharmacology, and you want them to prescribe medication, you need to teach them pathophysiology, pharmacology, and basically all of the basic sciences. You don’t teach them how to write a prescription – that’s not the first thing you do. You certainly don’t have the pharmaceutical companies come in and teach how to write good prescriptions.  ˇhe way information technology was being taught at the time was just that. You would bring in the big vendors, who would spend a week teaching medical students how to use their system and then reaping the rewards.

We had to figure out if there was a way to educate the students with the basic sciences about how to represent and use information, why to collect it in certain ways (and not in others), how you collect it is often times determined by how it will be used afterwards. It was a very interesting set of activities and much of that work is continuing even today.

LK: Teaching the actual care delivery, which health IT is a part, hasn’t until recently been a part of medical curriculum, and still only at a few medical schools so far. Now that we’re focusing economic attention on value and outcomes, you see a little more of it.

DF: I think we have to change the way to document care delivery. We use something called the SOAP Note (Subjective, Objective, Assessment, Plan) as an outline of how medical information is captured by physicians and others. The problem is that none of those talk about outcomes.

We talk about the subjective complaints, objective tests, physical exams and given that information, what is our assessment of what’s going on? And then we describe a plan of what we want to do. But, nowhere the approach to documentation do we capture what the outcome is. The next time you as a patient are seen, you talk to your medical provider about your subjective, objective, assessment and plan. But no one ever just asks the patient, “Did those medications work for you?”

As we think about value-based purchasing and quality measurement, we go through these conniptions to infer what the quality and outcome was, whereas sometimes, maybe we just need to ask the patient or have the doctor record what the outcome was. I think that there needs to be fundamental changes in medical school curriculums just for us to make outcome assessments happen.

LK: We work with a telemedicine company and your description of SOAP falls into our conversations. We talk about going from event-based encounters where a plan has to be made, versus a really longitudinal perspective. Information technology is just beginning to allow us to track a patient day in and day out, and this shift necessitates interoperability.

Interoperability is becoming an unusually hot political topic. Perhaps because of the high tech industry; some of it coming out of 21st Century Cures, the bill making it through the health committee; and some of it is with the Precision Medicine Initiative. There seems to be recognition that for medicine to move forward, it’s based on the availability of information. In your opinion, what’s going on there?

DF: I’ve tried to maintain for the last six years a consistent definition of what interoperability is. The first thing I can describe is what interoperability is not. It is not a state of utopia in which there is this information liquidity. You will hear this all the time: we want ubiquitous information, and free-flow, data liquidity and all those things.

But interoperability is not that state of the world. Interoperability is defined operationally. I use one of the definitions by the IEEE folks. The best version is that interoperability has two parts: the first part of the ability of two or more systems to exchange information and the second one – the one we usually overlook – is the ability of the systems to use the information that has been exchanged. It’s about exchange and use.

The example is that I use a Mac and you use a PC. I use my mail program and set up an e-mail and send it to you. We can exchange information if you open up Outlook and open my message. We’ve exchanged information. But, if I wrote my e-mail in German and you only speak French, then we’ve exchanged information but there’s nothing you can do with that information… unless you translate it.

The question is: have we had true interoperability? We’ve had exchange, but not really interoperability. The reason why I like the definition of exchange and use is that, when someone says, “I’m so upset, my system is not interoperable,” my first question can be, “What do you want it to do?”

Interoperability cannot be achieved in the abstract. It can only be achieved, given a definition, in the concrete. Interoperability is the exchange and use forces us to ask ourselves “what do we want to try to accomplish?”

When I was seeing patients at Mayo Clinic, I often worked in their Urgent Care Center. I saw a lot of folks that had been seen the night before, perhaps in the emergency room, and they just needed follow up.

Frequently, they’d come to me and have this yellow carbon copy that was written with a felt tipped marker, where the notes didn’t come through as well as they could have. I’m trying to look at this yellow sheet of paper to determine what medications they’re on, what tests they got, what were the results of the test, and it’s all scribbled at 3 o’clock in the morning and I can’t really read any of it.

If I had an electronic copy of that in my inbox, even if it was a scanned image of the original one, I’d have interoperability because I’d be able to exchange the information and use it for the purposes of understanding what happened that night before.

On the other hand, if my goal is to have that document and any new medications that they had been prescribed automatically incorporated that into my electronic health record, I wouldn’t have interoperability for that function.

Interoperability for legibility is different from interoperability for long-term care. If we have “exchange” and “use”, then it’s the “use” part that really defines what interoperability is.

LK: Where can we go from here in terms of the baseline of interoperability? I perceive there is a base level of frustration in the industry at large: how one hospital on one system can get basic information to another system. What are the best measures to figure out whether it’s about “uses” or about something else? How can we assess the quality of our interoperability?

DF: Healthcare is what I would term an “ultra large-scale system,” and a report that the Department of Defense did back in 2006 is illuminating. What do you do when you have a billion lines of code that all have to work together and seamlessly exchange information across these systems? The report was focused on communication and navigation and other kinds of systems, but does a good job of articulating the characteristics of a large scale system.

We need to frame the question. If you frame it as “we need to build some giant architecture that makes this all work,” you’re going to end up with AOL and not the World Wide Web. If you frame it around achieving a policy, like lower costs or higher quality outcomes, technology can help you get to that policy.

I think you need to think more strategically, realizing you are building an ecosystem, not a product. The large scale approach frames the problem better, accepting that we’re never going to centralize medical informatics; it’s always going to be decentralized.

The World Wide Web, which is probably the best example of a successful ultra large scale system, breaks down the technology into a fundamental stack of building blocks. One of our biggest challenges is that we haven’t thought strategically about how we create a set of fundamental building blocks so that the next use case can actually leverage what has been done instead of starting over with new approaches.

It’s sort of like those early telephone systems where they had all the cords and you had to pull the cord to connect it to the right connection. It becomes tremendously complicated because everything is a one-to-one connection; scaling becomes unmanageable.

Whereas, if as with the World Wide Web, you create individual packets to be routed and transferred, you can have set of standards rather than these one-off solutions.

LK: It seems like the lack of interoperability is in some ways used as a strategic advantage.  So how do we get from this insular or institution-based perspective of interoperability to a global perspective? Does it have to be a legislative solution? And how do we communicate and bridge to the consumer (which may actually be key to decentralized thinking)?

DF: There are three fundamental things we need to turn the ship in a better direction. The first step is I think we need to focus on those fundamental building blocks; for how we represent meaning, how we structure information, how we transport it, and how we secure it.  Those four things are really just an API.

But unless we think about what those fundamental building blocks are, even if we develop APIs, we’re still going to be in the situation with the switchboard and the cords. The building blocks are the first goal, and one of the pieces that’s missing is “how do we represent granular data” because most of our exchange right now is document centric.

We need to move from document-centric to data-centric exchange. We need to have a way to represent data at a granular level because that’s how we’re going to be able to calculate quality measures, that’s how we’re going to do decision support, and a lot of the other sophisticated computable things that we need to do.

The second thing we need to realize is that it’s very likely that we’re going to develop ecosystems with a high degree of interoperability within the ecosystems and a low degree between the ecosystems. It’s like smart phones or computers: some people have iPhones, others have Androids; some people use PC’s, some Macs, and some people use Linux.

APIs can be really helpful within an ecosystem but can be challenging between ecosystems. We don’t require that Android works on iPhones or vice versa, but it’s really useful to have ways of exchanging information between those things so that if I’ve got a PC and I’ve got my iPhone, I can still move music back and forth because there’s this thing called an mp3 or an mp4.

I think in healthcare we need that granular data that will help us develop good APIs and clinical decision support, but I need to be able to move from the Android system to the Microsoft system if I need to.  To me, that is having the ability for a patient to have a full extract in a computable, maybe not interoperable, but computable format that they could take from their Cerner System and move to their Epic system or take from Epic and move to NexGen system.

HIPAA allows that to happen but there’s been a lot of pushback and defenders would rather say “well we’re not going to give patients the entire extract, we’re going to give them access to selected information in an API that we develop.”  The issue with that it’s then the vendors who get to decide what information they share and what information they won’t.  That creates an establishment of those ecosystems and sort of locks them in.

If you can create a way of having granular data for these things like clinical decision support and quality measurement and the like, and the ability for patients to have a full extract of their information and actually move information between ecosystems, not entirely interoperable but at least computable, it makes it possible that things like precision medicine can be supported.

Precision medicine is about discovery of new associations and new ways that you can relate genetic information to behavioral and environmental and medical information.  API’s presuppose that you know precisely what information you need to share.  Precision medicine says, “We don’t even know what we’re looking for.”  So we need to have a way to have all the data accessible, to move between ecosystems and to be available for discover for science.

Categories: OIG Advisory Opinions

Nominate a Speaker For TEDMED

Sat, 02/06/2016 - 09:17

Neeti writes:

I am on the 2016 TEDMED speaker review committee/research scholar i.e. I am among the group of people who will be reviewing potential speakers for this year’s event.

If you know someone (does not have to be an MD or PhD) who is doing great work in medicine, public health and policy or education (any aspect of healthcare including basic science research) and would be interested in giving such a talk, please nominate them here. It is a short form which needs their bio and pitch for a talk, also a speaking sample in public domain (i.e. YouTube or Vimeo) if available but not a necessity.

A little background about their nomination process: “There is no deadline to nominate a speaker, and we accept nominations year-round.  Typically, we consider about 10,000 nominations for about ~50 spots on our stage, and are nearly done with the speaker selection process for this year.  However, if we receive your nomination after we have completed the selection process, we will keep it in our database for future years.”

This year, the conference is from Nov 30 – Dec 2, 2016 in Palm Springs, California.

Feel free to forward this to your friends/colleagues and if you have more questions, email me directly at

Categories: OIG Advisory Opinions

Biden’s Moon Shot and the 21st Century Cures Bill

Sat, 02/06/2016 - 02:19

Lawmakers in Washington are gearing up to pass major, far-reaching legislation on drug approval and cancer research. This is a good thing in the main but—no surprise here—Republicans and Democrats differ on approach and details, and things are already getting messy.

This makes the proposed legislation very risky. It could all implode in an election year, but momentum is building fast and both parties have something to gain by passage.

This blog is a primer on what’s happening. Future posts will track the legislation’s progress and delve into some of the issues at stake. Comments are invited.

As you’ve no doubt heard, the White House—with Joe Biden in the lead—has proposed a “moon shot” on cancer research. The administration is expected to propose, in its FY 2017 budget request, $755 million in funding for the initiative, with $195 million of that earmarked for the National Institutes of Health (NIH) and around $75 for the FDA.

Importantly—and you’ll see why below—under the budget deal agreed to in December for FY2016, NIH’s budget was already boosted by $2 billion, with $264 million going to the National Cancer Institute. That was an unprecedented 6% boost after many years of minor or no increases. (A promise of an additional $9 billion for NIH over the next 5 years was also made.)

Among the major goals of the moon shot initiative, according to the White House: launch and complete clinical trials for up to 20 kinds of cancer in as many as 20,000 patients by 2020, with a focus on advancing breakthroughs in immunotherapy—by all accounts the most promising area of cancer research at the moment.

Researchers are already lining up to capitalize. On January 12, a group of leading researchers and drug companies, including Amgen and Celgene, launched “The National Immunotherapy Coalition: Cancer MoonShot 2020.” The stated aim: accelerate the potential of combination immunotherapy as the next generation standard of care in cancer patients.

Meanwhile, lawmakers in Congress are processing a bill dubbed “The 21st Century Cures Act.” (I’ll abbreviate as “Cures.”) It was written by Republicans and emerged from the House Energy and Commerce Committee led by Rep. Fred Upton (R-Mich.). The bill, in a nutshell, gives FDA a batch of new tools to expedite the approval process for new drugs and medical devices. One of those tools would allow the FDA to approve new drugs based on a wider range of research results than is the case now.

The House passed the Cures bill in July, with bipartisan support.  Notably, however, support from Democrats came almost entirely from a provision in the bill that increased NIH funding by $2 billion.  Most Dems were worried about the FDA provisions but strategized that the Senate would very likely modify those anyway—hence the bill got their vote.

As referenced above, that $2 billion increase for NIH was “borrowed” from the bill in the 2016 federal budget agreement, which became law in December. That served to undermine support for the Cures bill in the Senate, and some thought it might be dead—if not forever at least until after the election.

Then along came moon shot. It appears to have reenergized chances for the Cures bill. Upton and other Republicans are doing everything in their power to leverage moon shot to gain Senate passage. The White House—or more precisely Biden—has signaled a willingness to go along with that. But Republicans in the Senate now say they plan to chop the bill up rather than pass a single piece of comprehensive legislation.

The Republicans move reportedly blindsided Democrats and threw the process into chaos, with Democrats suspicious of Republicans’ motives (again, nothing new about that). Democrats have also stated clearly—led by Patty Murray of Washington state, the ranking Democrat on the Senate Health, Education, Labor, and Pensions (HELP) committee—that they will not support the Cures bill without the additional funding for NIH and FDA that the White House is now calling for, and over multiple years.

Meanwhile, Sen. Lamar Alexander (R-Tenn.), chairman of the HELP committee, has said that breaking the legislation into parts allows the committee to agree on the least controversial parts first and then figure out the rest.

On yet another and separate track is the President’s Precision Medicine Initiative, launched in 2015. It’s been funded to the tune of $200 million so far, with more likely to be proposed in the 2017 White House budget request. In the White House’s words the initiative is “a bold new research effort to revolutionize how we improve health and treat disease….that takes into account individual differences in people’s genes, environments, and lifestyles.”

All these initiatives are related, of course. And it is a positive development that policymakers are focused on increasing the funding of and improving medical research and new ways to treat disease.  But buried in the Cures Act, the cancer moon shot, and the precision medicine initiative are some poorly conceived ideas and unrealistic assumptions.

For example, the House version of Cures has been roundly criticized for creating a possible end run around the gold standard for drug approvals: controlled clinical trials. And the cancer moon shot has spurred jeers in some high-level corners of medical research for being overly optimistic about the pace of scientific progress against what is a highly complex constellation of 100 or so different diseases.

Those issues and more will be the subject of future blogs.

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.

Categories: OIG Advisory Opinions

The Secrets of Cancer Survivors

Sat, 02/06/2016 - 01:02

Disclaimer: I have never had cancer. Therefore, at the most basic level, I do not have the right to pontificate about dealing with the dread disease.

Rather, I have been the servant and support of those that struggle with cancer. I thought it might be of some assistance to share my observations from the other side of the bed rail. Perhaps, their secrets of survival may help you.

1. Cancer is a team sport; do not do this alone. Never show up to an important appointment by yourself. You are dealing with a physical impairment, as well as a complex mental challenge, at the same time that you are frightened and do not feel well. Have someone with you to listen, ask, take notes and simply carry your things. This is true not only during treatment, but at home. Accept support. Build a team. Work together to fight this awful thing.

2. In the same way, whether you like it or not, a family goes through this together. Those that love you, also “get cancer.” Working together helps everyone deal with the affects of the disease. You are not a burden. You reap what you sow.

3. Nonetheless, it is also important to get time for yourself. You need grounding time; quiet moments to heal. Take a deep breath; rebuild. If your family does not understand the importance of “me time,” show them this note.

4. Be on time for your appointments, tests and treatments. This is my own hang-up, but being on time is part of being organized and I have noted that the patients that are punctual are organized and those that are organized do better.

5. Be whiney. Really, complain a lot. Tell your doctors what is happening. Take notes. Email. Call. Will the doctor give you his cell number? Do not ignore a fever for five days, crawl into the doctor’s office, and say, “By the way, I feel terrible.” That will result in the doctor saying, “By the way, time to go to the hospital.” This is why women make better patients then men; malignant macho.

6. Get in shape. Before cancer. During cancer. After cancer. The more physically active, the better your body can fight illness and the less side effects you will have. Exercise not only prevents recurrence, but allows more rapid recovery. Walk. Row. Swim. Bike. Sex. Do not be a dead blob.

7. Taking the exercise theme a step further, I have seen that those that do “alternative exercise” seem to do better. Yoga, Tai Chi, Pilates, Jazzercise, kickboxing, Recki, and a host of others seem to have remarkable benefits. Acupuncture, acupressure, Shiatsu, Jin Shin Do and chiropractic techniques rejuvenate many of these same patients. Stretch your comfort zone.

8. Be on time for your appointments, tests and treatments. This is my own hang-up, but being on time is part of being organized and I have noted that the patients that are punctual are organized and those that are organized do better.Be whinny. Really, complain a lot. Tell your doctors what is happening. Take notes. Email. Call. Will the doctor give you his cell number? Do not ignore a fever for five days, crawl into the doctor’s office, and say, “By the way, I feel terrible.” That will result in the doctor saying, “By the way, time to go to the hospital.” This is why women make better patients then men; malignant macho.

9. No, I do not believe in vitamins. I have never seen them help. The data is poor and I can think of no reason that a pile of chemicals thrown into a tablet in some mad scientist’s lab, can improve on the body’s natural nutritional intelligence. The body knows what it wants and expects to receive vitamins in the balanced form of food. If it tastes bad, the body does not want it. If it tastes good, your body is broadcasting a need. Eat lots of fruits, vegetables. Limited red meat. Hydrate, hydrate, hydrate, hydrate, hydrate. Did I mention the importance of hydration?

10. Do not smoke. Stop immediately. To be clear, if you have cancer and continue to smoke you are wasting your time and money visiting a doctor. You are screwed. Stop. Patients who continue to smoke, die.

11. Limited alcohol. Note, I did not say none…1-2 drinks a week, seems to be OK. However, the 96 year-old who consumes two scotches a day is exceedingly rare.

12. Understand your disease and therapy. It is your body, your life; you have to be in control. I love doctors, some of my best friends are doctors, but they are only teachers and guides. If you are going to get the best care, it will be the care that you think and understand to be best. Ask questions… lots of questions … create lists. Your doctor does not mind, because it focuses the conversation.

12. In the Internet era, it is easy to build a baseline of knowledge. However, take anything you read online with a grain of salt. It is general knowledge, not personal prescription. The Internet can be a scary place, so use it only as a place to start. Ask your doctor.

13.Find ways to deal with the stress. Family is the start, but support groups, counseling, hobbies, short trips, reading, writing, Facebook, can help the cure. Emotional suffering can drain you and make it hard to go on. Talk to your friends, family and doctor about alternatives. The most “successful” patients achieve emotional balance.

14.Joke. Tease. Humor is a powerful weapon against despair and depression. Watch comedies. Read funny books. Joke with your caregivers. This is no more arbitrary than oxygen.

15.Sob. Scream. Fight. Break things. Yell. Bitch. Get really pissed off. Shout now, apologize later. Purge the pain that is trying to eat you up. Let it out. “F**k this s**t.”

16. Did I mention laughter?

17. Recognize that your life has changed.Permanently. Cancer is like other major transitions in life … graduation, marriage, kids. It is just one you did not want … like divorce, flood, losing your job. Work to understand the new you.

18. Recognize that life is the same. You are still you. The things you love (or hate), your view of life, the things most important, are the same. When the chaos settles, in the moments of quiet, you are still there.

19. I do not understand this one, but pets definitely have healing powers. I am not certain what it is about a sad-eyed dog or a purring ball of fur that gives solace. My mother had two cancers. Her cat, Linda, used to bring in dead birds when she was weak in bed. Somehow, that motivated her to get up and going again.

20. Make sure your doctors are communicating with each other. In the best of all possible worlds, they would do this without your prodding. However, you must play secretary; bring back and forth notes and records. Confirm they are talking to each other. Like I said, this is a team sport and it is vital that your professional caregivers function as a team. The most “successful” patients track records and the interactions of everyone involved in their care.

21. Get a second opinion. Or third. Fourth? The worst thing that can happen is that everyone will learn something. Your doctors do not mind. If they do, they probably should not be your doctors.

22. Care about your appearance. Stay groomed and clean. Dress nicely. As they say, the cloths make the man … or woman … and a well-clothed patient is a healthy patient.

23. Try to leave the cancer and the treatment in the doctor’s office. This is very hard to do, but as much as you can compartmentalize the disease, leave the burden somewhere else, the better balanced your life.

24. Attack… attack … attack. Successful patients and doctors know that persistence works. Uncover every stone. Destroy every disease. Be realistic, do not ruin your life with worthless toxic therapy, but consider every chance to kill cancer.On the other, other hand, stay involved with day-to-day life. We are social beings. Go to weddings, picnics and holiday events. Children’s soccer games mend better than antibiotics. Yes, it can be discouraging that you are too weak to dance, and frustrating to use a wheelchair in an airport (although the airlines are great about it, just call ahead). It is hard when you are at the Thanksgiving table and cannot eat. It is much worse, even dangerous, not to show up at all.

25. Do not crawl into a corner and become a cancer patient. In your body, somewhere, is the growth called cancer, but that disease is not you. You are not cancer. You are a wonderful, powerful, intelligent, important, loving and magical being. Do not sit and wait for the disease to go away.

26. Live. Love. Life.

James Salwitz is an oncologist based in New Jersey.

Categories: OIG Advisory Opinions

David Vivero, Amino– Yes, We Need Another Doctor Search Company!

Fri, 02/05/2016 - 20:47

Those of you dismayed at the dearth of recent interviews of notable health tech startups on THCB will be glad to hear I have several in the can and will be putting them up starting with Amino today. And the rest of you can move along….

David Vivero made his money at a company matching renters to apartments that ended up part of Zillow. That was too easy, so now he’s decided to match people up with the right doctor. Amino came out of stealth late last year with about $20m in funding and it has acquired large data sets (including being one of the few with official access to all CMS physician data) and some complex ways to match patients to doctors–the primary one being doctors near you that have seen a lot of patients like you. Why are they in a  market that already has several well known & well funded players like Vitals, Healthgrades, Better Doctor and more? David told me that and more in this interview.

Categories: OIG Advisory Opinions