Improving Access to Care or Lowering Quality

At one time in order to get the healthcare you deserved and/or needed it was like playing darts. Your physician was the bull’s eye in the center. If it was the weekend or late at night and the need was acute enough it would be emergency room which is the next ring out from the bullseys. Finally there was the pharmacist and pharmacy where you went for poison ivy, medication side effects, diaper rash, etc. There you were likely to get advice and move along. The physician and her office was the sun and we patients were the planets revolving around. But that is changing where the patient is moving closer to the center.

The Economist has an article Medicine at the Mall which tells the story of how clinics are becoming more convenient. Walgreen is leading the change and providing patients with healthcare becoming easy. They are moving the pharmacy to the bull’s eye. Of course there have been urgent care centers and worksite clinics etc. But this move by Walgreen’s 372 pharmacy clinics and CVS Caremark’s 640 offers patient 1,012 new sites to find healthcare easier and more conveniently. Do not mistake this trend for some new healthcare disruption. These pharmacy chains are looking to partner with local hospital networks. What this is a way for patients to access healthcare on their terms matched with their needs. It is moving pharmacy to toward the center and offering patients a larger target. I would agree with Dr. Ryan this trend may be taking quality care away from the primary care physician but I would offer that these new venues and the PCP need to work together to deliver the highest quality care.

One point I want to make, no plead with the Economist shit can the stock photo or do a better job finding suitable art. 

Your Guess is As Good As Mine: Or Bayesian Logic Rocks

My favorite marketer and all around technology writer Digital Tonoto has a very interesting post titled “Bayesian Strategy”. Greg’s primary argument is that ‘…the false certainty that planning engenders is becoming an impediment to, rather than a tool for, attaining objectives.’

Technology cycles are shrinking and to plan for something that will change in a matter of months not years is a doomed exercise. We are currently using controlled variables and huge sample sizes to determine conclusions that are statistically significant and treated as true. As Greg next points out Nature recently published an article showing that the majority of cancer research could not be duplicated. Makes me stop to think if they can’t do how can we?

Greg argues that a better alternative is the Bayesian method where a guess is made and the data collected to demonstrate right or wrong in your guess. Waiting to test variables over time to prove right at a time when business cycles are moving at the speed of light may leave many good ideas behind. We could be doing more simulation testing or scenario planning.

What does this have to do with social media, medicine, patient outcomes, and improved healthcare? Everything. Today there are hundreds if not thousands of healthcare apps, everyone and most healthcare corporations are creating twitter hash tags or Facebook pages. Facebook likes and Twitter followers are driving the explosion of social media and providers. Just look at the Cincinnati Business Courier articles on social media and healthcare.  There is not a shortage of trials and errors in healthcare. Can we say what is being done is Bayesian? Needless to say it is a boom time. Healthcare is a growing sector hiring at a pace faster than the economy is growing. That lends itself to Greg’s argument that Bayesian is better. .

I am of the opinion that though many of these social media efforts are being done as part of a strategy to improve outcomes the majority is being done because social media is trending. Or it is being done to sell a product or service. Nothing wrong with that but, I fear it is supplanting the goal to improve outcomes and healthcare in America. And worse we will lose the magic of social media as it becomes a co-opted sales and marketing tool.

My guess (Bayesian) on improving healthcare is centered on two items. One is the patient physician connection. On the whole we trust our physician more and to a greater degree than any other resource. When that connection works it’s an amazing ebb and flow of information, communications, and trust. We say x to our physician and if we are lucky he/she listens. Our physician says for us to do this, we do it not because they are wearing a white coat but because we understand where that knowledge comes from and its place in our lives. We want to learn and succeed. Our physician wants us to learn and succeed. We participate in our healthcare with our physician. The sad reality of my Pollyanna outlook is that HCP don’t have the time to do this. But we need to try and find solutions not just to patient care but HCP time issues. 

This brings me to the second item knowledge/information used by patient’s drives healthcare changes. In medicine the physician is engaged in life-long learning. Similarly the patient who is seeking solutions to healthcare problems is equally involved in learning. The data is there, patients and consumers are using the Internet to search for healthcare information. They are demonstrating their desire to learn.

My hypothesis or guess is:

When knowledge and information between patients and healthcare professionals is at the center of care it improves patient health, reduces HCP time, and yields durable outcomes.

Right now we’re not maximizing the benefits of social media to patients, HCP, and healthcare in general. We are not guessing, what’s the strategy to improve healthcare knowledge among patients, and collecting data to adjust goals and strategy. It seems all we are doing in large part is throwing up feeds, links, and pages. I am not sure we are even planning as much as just executing. I realize this is medicine and it is has the baggage of evidence based knowledge as well as entrenched beliefs and attitudes. We can do this we can make it work if we set goals with a strategy and execute it all the while measuring and studying its effect and outcomes

Healthcare Cost, Patients, Social Media and You and I

This post may end up being a hot mess of disparate items never strung together like 10mm Mikimoto pearls. Consider that my black box warning.

Carolyn McClanahan a contributor to Forbes, physician, and financial planner published a column yesterday “The Problem With Patients In Controlling Health Care Costs”. Her column is drawn from a larger article in Health Affairs by Rosanna Sommers, et. al. Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs. I am going to get Sommers article (it’s behind a damn paywall) and take a long look at that. But for now I want to speak to the larger issue that troubles me and perhaps others regarding what McClanahan presented. There are four primary challenges we face in trying to fix healthcare cost in the US that came out of these focus groups in the Health Affairs article.

They are:

• Patients only want the best: Patients see the more expensive the treatment the better. And if the patient is not paying for it (i.e. insurance, Medicare, etc.) they want what they want no matter what the cost. I wonder how often the family is driving that message?
• Reluctance to make trade offs between health and money:  As McClanahan states ‘poor health creates poor finances’. People need to connect their health with their finanical health and plan for that illness or injury which is just down the road. Wellness and prevention is key. But in the focus groups they are not seeing that.
• Lack of interest in cost others pay: People feel they didn’t cause the crisis in healthcare so it’s not their problem.  These  focus groups just wanted to get what they could since it was costing a large corporation and not them.
• Noncooperative Behavior: Those in the focus groups felt personal interests won over the good of all. Why should they care if no one else is caring about cost.

These are only focus groups yet their opinions are on the depressing side of reality. I need to buy the article to see the make up of the groups, age, gender, economic status, etc. But even without that data this is troubling on many levels. It speaks to the larger issue, there are a group of people, not a subset, who seemlying ignores or doesn’t care about issues well within their capicity that can drive down the cost curve on healthcare and improve outcomes.

McClanahan presents three solutions that are helping to drive costs down while maintaining and improving outcomes.

• Palliative Care Movement which I have written quite a bit about here and other places.
• The Choosing Wisely is a movement and report that is trying to educate physicians and patients about unnecessary tests and treatments. There are 35 speciality societies that have identified many procedures and treatments are not effective. Their hope is to reduce how frequently patients ask for unnecessary care and aid physicians in turning these requests down.
• The National Institute for Health and Clinical Excellence (NICE) this is a program from the United Kingdom which brings cost into coverage decisions showing what the best care for the cost is.

 Okay that is the article. I plan on getting the full article from Health Affairs and do a deep dive. But I am scratching my head. I just looked at “Twitter in Healthcare” from the Institute for Health. 66% of internet users looked for information about a specific disease. WebMD top five conditition are shingles, gallbladder, gout, hemorhiods and lupus. 56% of WebMD users sought information about pain relievers, anti-depressants, HTN medication, and hysterectomy. The percent of total internet users looking for medical information online were 24% drug safety and recalls, 14% memory loss, dementia or Alzheimer’s and 17% for chronic pain.

On one hand we have a group of people who are cost deaf and appear to be selfish. On another hand we have learners activly seeking knowledge about healthcare problems they want to solve. And on our third hand we have a small but highly active group of people seeking to expand and grow social media in healthcare. These groups overlap but I am not sure there is data that tells us what segment of the cost haters are seeking information about shingles and what is their motivation in learning. Do we know what the social media healthcare cognisenti do that is driving cost haters with shingles to use the internet to learn? These are gaps that we have that are impeeding our ability to apply social media tactics to healthcare strategies.

 One final observation to add:

This guy tells me he is all for gay marriage but really just wants to get on @BuzzFeed http://t.co/HqpvtZvIpy

The above is from the NYT blog of SCOTUS coverage on the DOMA case. I think this speaks to a larger trend where we (the editorial we) are motivated by our online life to ‘get on Buzz Feed’ or to just do something to advance our 'brand'. We are abdicating control of knowledge and information to companies who have financial goals and not outcomes and patient care goals. This will only grow as time moves forward. If we are off one degree today, in five years it will be 20 degrees. Are we leveraging social media for self-exposure at the expense of improved patient care? Perhaps all these little pieces are being put into place like mosaics and soon it will be a Gaudi Cathedral. Or is this what one person does here benefits someone over there. A butterfly flaps its wings in China and someone sneezes in Cleveland. My small post becomes an idea for Mayo Clinic. Only time will tell. 

Is Your Wallet Ready for a Scorpion Bite?

I can't even think of what to say so here is the full text from Healthcare Fees

If you ever get bit by a scorpion, be ready. The cost of treatment at one hospital is going to run you over $80,000. You will receive two doses of Anascorp. Each dose costs over $39,000 dollars. If you have insurance, you will be required to pay about $20,000 of that bill. These costs are for a patient that went to a out-of-network hospital. If you are in-network, the cost can be as low as $7,000 per dose.

Sea Change or Out at Sea With Healthcare in America

This past Saturday marked the third anniversary of the Affordable Care Act’s (ACA) passage into law. The Yale student newspaper published a short article on that and the expose written for Time magazine on March 4 “Bitter Pill: Why Medical Bills are Killing Us”. The author of that 24,105 word article was Steven Brill Yale Law Class of ’72 (you wonder why they are running this article). Readers of this site are familiar with the article and its premise transparency in pricing of hospital bills is nonexistent and needs to be changed.

I posted a link to an article in the LA Times yesterday ‘You Want a Knee Replacement? I’ve got a Deal for You.’ The LA Times article was about ways to find competitive pricing for healthcare procedures. It is a start in trying to get transparency into the system.

Are we beginning to witness a larger more important sea change in healthcare with all the various disparate pieces coming together? When you think about it the genesis was perhaps the ACA or the aging population and the associated spiraling cost. Perhaps it was the economic downturn. Wherever it started today we have changes afoot. People, consumers, patients, and caregivers are learning to and are solving healthcare problems they are having. And with solving their own problems they may just be solving the countries bigger healthcare problems.

My hope is that these beginning small steps are a movement that will take hold. Perhaps we’ll see better patient outcomes and lower costs but I am realist and cynic. Though hospitals are buying physician practices as well as hospitals in hopes of locking in a region to control price and the marketplace the reality is insurance companies are ruling the roost. They are the one distributing the money and controlling prices.

Do you think we are turning a corner or just standing in place? Maybe I am drinking the Pollyanna Kool-Aid. I think there will be more pressure for better changes. I think I see where this may be going but I thought Lotus Notes was cool.