Notes & Links: October 29, 2013


Making Health Addictive
Joseph Kvedar writing on HealthWorks Collective is presents the premiss that people’s addictive relationship with their smartphone can be leveraged to improve health. Kvedar admits right up front “…is there any way health can really be addictive?  Probably not.” What he wants to present is the “juxtaposition of motivational health messaging with some other additive behavior, specifically checking your smartphone.”

Next comes the science of checking our phones 100 times a day (I’ll raise my hand) and how that is addictive and it releases dopamine associated with ingestion of addictive substances. Yup we get off on our phones looking for emails, stock news, weather reports, news, cat videos, etc. So far still good.

Why are smartphones so additive? All the apps, video, social networks, and just plain curiosity. Kvedar makes the following statement.

Many have talked about the transformational possibilities of mobile health including:  the opportunity to use an always on, always connected device to message you in-the-moment about health; to capture health-related information about you via the camera and through connected sensors; and, of course, the ability to display relevant information in context.  All of these are exciting, but if we can exploit the addictive quality of smartphones, it will be the most important characteristic of mobile health as we move forward.

Here are his strategies for doing the above:

1. Make it about life: Learn what the person wants from life his/her aspiration and tie health related messages to those aspirations.

2. Make it personal: Put it in the context of the phone user in relevant ways. Personalized medicine

3. Reinforce Social Connections. We all want connections to others and especially around health problems or questions we are seeking to solve. They are very powerful tools and as Kvedar notes not just for friends and family but for accountability and adherence to care and wellness plans.

Here are the tactics that are offered:

1. Subliminal Messaging. “Imagine if every time you checked your phone, an unobtrusive brief message appeared on YOUR health issue and how to improve it.”

2. Use Unpredictable Rewards. ” B.F. Skinner proved that operant conditioning is more effective when the stimulus and reward are tied only some of the time.”

3. Use Sentinel Effect. “This effect of having an authority figure look in on your life is a really powerful tool that can be used to effectively promote good health through mobility.”

Kvedar ends with reference to this in the Boston Globe

What’s going on here? We’re witnessing the death throes of advertising’s “Mad Men” era, and the birth of the Mr. Spock era. Mad Men were all about coming up with clever ideas for ads, treating clients to steak-and-martini dinners, and putting TV spots on the most popular shows. You didn’t know exactly who saw your ad when it ran on “Bonanza,” or what impact it had on sales, but you knew it reached a lot of people.

Mr. Spock is all about making logic-driven decisions based on data collected about consumers and the context surrounding the ad. Who is clicking, and is that click leading to a transaction? Is this ad worth what we’re paying?

I agree with his premiss we should leverage the smartphone we are all addicted to in order to maximize the technology that will drive outcomes and improved patient care. I agree that for this to work we need to determine what the patient wants or needs. Where I split hairs is around how we do that? Using surrogate markers of sites visited or other behaviors on the phone or even the computer is not accurate and may not directly address the problem the patient wants to solve. What needs to be done are for patients to say I need to understand this about myself and my health. I want to opt in and I want to opt in with a trusted partner or partners.

The problem here is that will we ever reach a critical mass of patients who will drive community outcomes? Will we be able to go beyond those who are active healthcare participants and move to the next demographic those who have a minor interest? This is similar to getting the young invincible’s to sign up for ACA. How can we apply all these ideas to successful marketing?

Overcoming Fragmentation in Health Care
John Noseworthy writing on the Harvard Business Review Blog Network addresses the reality that the quality of healthcare in America is fragmented which drives ‘unsustainable health care spending.’

Noseworthy points to the fact healthcare is in the throws of consolidation through mergers and acquisitions and that is at the root of fragmentation because the larger and more complex a system becomes the greater its fragmentation and cost.

It is different at the Mayo Clinic

At the foundation of our approach is a knowledge-management system — an electronic archive of Mayo Clinic-vetted knowledge containing evidence-based protocols, order sets, alerts and care process models. This system, which can be made available to physicians in any location, brings safer care, better outcomes, fewer redundancies, and ultimately cost savings for our patients. Ask Mayo Expert, one of the many tools in our system, helps physicians deliver safe, integrated, high-quality care. Through this system, physicians can find answers to clinical questions, connect with Mayo experts, search national guidelines and resources, and find relevant educational materials for patients. This knowledge is updated in real time and made widely available.

Knowledge and access to knowledge is the single most important driver of better patient care. HCP are life long learners and being able to quickly and easily access experts etc. will slow fragmentation and hopefully slow cost expansion. And that is achieved through the following activities

Through this commitment, Mayo Clinic physicians and scientists have contributed more than 400 peer-reviewed papers on quality improvement in the last five years.

Noseworthy ends with this

To transform health care in America into high-quality, patient-centered care that the nation can afford, we must address fragmentation, we must address variable quality, and we need to create a sustainable health-care financial model. Collaboration is key. Mayo Clinic has a long history of innovation focused on improving the value of health care, but we can accomplish much more by working together — integrating and sharing knowledge with one another.

This is mom and apple pie and spot on regarding learning and how it drives change. What was missing for me was the patient component. Clearly Mayo Clinic is patient centric in its care. That is known and proven but I was surprised to see it not referenced or tied to this article. Fragmentation is the the goal of the institution but the patient is at its center and can benefit if not address fragmentation. Just to make sure I didn’t miss a patient reference I searched the article and the only reference to patients was in the comments.

Great blog! First off, please let me commend you on the amazing work that you, your organization and your employees do everyday. The software you reference to address fragmentation on the hospital side sounds fantastic! May I ask how you are addressing fragmentation in the eyes of the patient? We launched a pilot program in Cleveland, OH that used Lay Patient Navigators to decrease fragmentation. By developing key relationships with patients, the lay navigators were able to massively decrease fragmentation and positively impact patient outcomes. It was a very successful program! Not only did it decrease fragmentation and increase both outcomes and patient satisfaction – it also positively contributed to the hospital’s bottom line! Just another way to think about decreasing fragmentation in the eyes of the patient because as we all know – this health care system is incredibly fragmented and confusing! Do you use lay patient navigators?

We should not forget that the patient is at the center of care and they drive our brave new world of patient engagement. 

The legal justification for mandate penalty/open enrollment realignment
Nicholas Bagley a University of Michigan Assistant Professor of Law submitted a quest post to The Incidental Economist. Let me see I can explain this, the Obama administration offered guidance to ease concerns surrounding the imposition of the individual mandate using “hardship exemption”.

Here’s what the administration is worried about. Under the ACA, an individual doesn’t get slapped with the mandate penalty until she’s gone without health insurance for a full three months. That means she’s got to be covered before April 1 rolls around—which is to say, by midnight on March 31. By regulation, a plan that is purchased in the first half of a month takes effect on the first day of the following month (e.g., a plan bought on February 10 takes effect on March 1). For coverage purchased in the second half of the month, the coverage period starts on the first day of the month after that (e.g., a plan bought on February 20 takes effect on April 1). As a result, to get coverage that kicks in before April 1, an individual has to purchase a health plan by mid-February.

Yet the open-enrollment period lasts all the way through to the end of March 31.

Still, the administration is right that the awkward conjunction of the ACA and the coverage-effective dates has created a trap. Pretty much everyone who purchases insurance in the open-enrollment period will assume—reasonably if wrongly—that they’ve done what the mandate requires of them. That shared assumption provides an eminently plausible basis for invoking the hardship exemption: the assumption, by encouraging delayed enrollment, means that loads of people will face a financial penalty they hadn’t anticipated. That penalty, even if it’s assessed after the fact, will reduce their “capability” to afford the health plan that they purchased. Invoking the hardship exemption to deal with that reduction in capability makes sense, especially because the whole point of the exemption is to alleviate affordability concerns.

I have a headache trying to figure this out and understand it. Bagley has some terrific links and information which helps.  But more importantly I believe the ACA is organic and will move forward in fits and starts to what I hope becomes a valid and working healthcare model. What frightens me is the fact that this looks like how sausage is made at its worse. I wonder how much faith we can hold on to while we wait for some positive metrics?

Notes & Links: October 28, 2013

What the ad biz needs is to exorcize direct marketing

Doc Searls Weblog begins with a Michael Wolff’s article in USA Today “What ad biz needs are writers“. Searls primary message in this piece is that advertising and direct marketing were kept apart with top notch writers, art directors, creative directors, etc. wanting to go into direct marketing. And as Searls points out. 

In the online world, advertising messages are not much about increasing brand awareness, or other old-fashioned advertising purposes. (Though today’s ad folk love to throw the word “brand” around.) Instead the main purpose is getting direct responses: clicks and sales, aimed by personal data, gathered and analyzed every possible way. The idea is to  make the advertising as personal as possible, as far as possible, regardless of how creepy it gets. It’s all fully rationalized. (Hey, you canopt out if you don’t like it.)

Terry Heaton in Street Fighting Magazine is quoted

Operating within the soul of every marketer is the ridiculous assumption that people want or need to be bombarded by advertising, and that any invasion of their time or experience to “pass along” an attempt to influence is justified. If this were true, there would be no looming fight over DVRs, which allow viewers to skip ads. You have no inherent right to my eyeballs, and it is precisely this axiom that makes today’s instruments and gadgets so powerfully disruptive to the culture

What we have here is the fact technology is changing marketing. It is timely that the next post from Greg at Digital Tonto takes us into the future of marketing. 

The Future of Marketing

Greg writing on Digital Tonoto points us toward the future of marketing. And in todays techno world Greg sums it up nicely when he says “…brans will have to learn to be more like publishers and develop content skills. It also means that marketers will have to create a genuine value exchange rather than just coming up with catch ad slogans and price promotions”

Greg points out the following:

  • From Rational Benefits to Passion Economy
  • From Strategic Planning to Adaptive Strategy
  • From Hunches to Simulations
  • From Brands to Platforms 

This is a great read full of ideas and links you won’t find elsewhere. And with Twitter Chats like #hcsm what Greg offers us are tools, ideas, a directions for those of us interested in healthcare to focus and build. We are marketing outcomes, care, management, cost, etc. It’s time we had the tools to think of it that way. 

Sugar Linked To $1 Trillion In U.S. Healthcare Spending

How sweet it is. Dan Munro Contributor at Forbes takes a deep dive into the Credit Suisse report on sugar and finds this pearl:

So 30% – 40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.” Credit Suisse Report

This is a financial report about the sugar industry, which the US subsidizes in a big way. Americans pay three times the world price of sugar to the tune of about $3 billion a year in estimated taxes. See the full article here. In essence we pay to get sugar and we pay to fix what sugar broke. 

What is of interest is how detailed this report gets into the health aspect of sugar. And below is a chart “Annual Global Soda Consumption Versus GDP per Capita” Check out where the USA sits. No where near the trend line so far above it think heaven. And you really need to see the chart titled “Average Daily Caloric Intake of Sweeteners By Country”. 

Notes & Links: October 25, 2013

Raising the Medicare eligibility age is now a REALLY bad idea
Aaron Carroll and Austin Frakt at The Incidental Economist give us all the smart economic reasons why raising the eligibility age for Medicare is dumb. 

Put these two things together, and the new estimate for federal savings is much lower than it was before. But all the non-federal costs (not in the CBO report but covered by us before — see links above) remain, as does the concern about the viability of the exchanges and the fact that Medicaid hasn’t expanded in all states. So if raising the Medicare eligibility age before was a bad idea (and it was), it’s an even worse idea now.

This is a great smart clearly written read.

FDA to Regulate Gluten-Free Labeling
Jennie Bragg at Healthworks Collective shares the new FDA rule on what a product has to do to be labeled Gluten-Free.

…a food or beverage must contain fewer than 20 parts per million (20ppm) of gluten. This translates to approximately two-hundredths of a gram of gluten per kilogram (2.2 pounds) of food.

I can’t help but wonder if some of the foods currently saying Gluten-Free who have sales that show many people buying them and feeling better will end up not making the cut because they are not strickly Gluten-Free. Can you say placebo effect?

GOP’s Oddest Obamacare Objection
Michael Millenson a Contributor to Forbes shares his shock and awe at the the following:

The reason that Republicans shut down the federal government, it turns out, was to “restore patient-centered healthcare in America.”

Really? Worried about patients and patient centered care? The GOP? One quote to capture the complete and utter lucency of this. 

Obamacare opponents assert that the ACA undermines the traditional doctor-patient relationship – although I suspect that being able to pay your doctor because you have health insurance actually improves it quite a bit. Yet in calling for “patient-centered healthcare” instead of the more common “patient-centered care” or even patient-centeredmedicine, conservatives unwittingly abandoned doctor-patient language in favor of business-speak.

Go read this piece and smile.

Polio eradication: where are we now?
The Lancet editorial reminds us that it would be wrong to forget this disease still exists, still can cause suffering, and still needs world attention. 

With regard to the technical dimension of ending polio, global eradication efforts led by WHO, UNICEF, and the Rotary Foundation have made remarkable progress. Poliomyelitis cases have been reduced by more than 99% and there are only three remaining polio-endemic countries—Afghanistan, Nigeria, and Pakistan. In 2013, the number of polio cases from the three endemic countries—99 in total—is 40% lower than in 2012.

Technically we cannot do better at eradicating this disease it is now a battle of political will. 

Shine again
Jonathan Barnes writing in The Lancet reviews Stephen King’s new novel a sequel to The Shinning titled Doctor Sleep. When I saw The Lancet had a book review I was drawn to like link bait. The book follows Danny the son from The Shinning into the 21 Century where he is a physician working in a hospice in New Hampshire. 

The review is good and the fact it is in The Lancet and ties the loose ends of addiction to King and his previous work is interesting. 

Notes & Links: October 23, 2013

Austin Frakt writing in The Incidental Economist shares a chart from NY Magazine article by Stepen Hall on the cost of cancer drugs. Here is the chart showing the rising price of oncology drugs since 1966 at the time of FDA Approval. Austin implored readers to read the article to the end. I am such a compliant (PC incorrect term) reader (patient too) I read the article. Here is the link to the charts are MSKCC and PowerPoint slides.

I fully agree with Frakt read the excellent and telling article to the end. There is so much there to cull, learn, and act on. For my reading I came to this having worked on Adriamycin and other cancer drugs going back to 1985. With that particular history I can’t help but look at this this article and wonder if Zaltrap is being used as part of initial therapy with some off label messaging? The firewall for that is clearly the oncologist but we know that:

And because the economics of cancer drugs have always been colored by emotion, where patients facing a grim prognosis are desperate to try anything (as are their doctors)

This is a very powerful and telling quote 

Kantarjian has brought a rhetoric to the price debate that is unusual for such a prominent figure in oncology. He accuses the pharmaceutical industry of “greed” in its pricing of CML drugs, argues that “there is zero correlation—zero—between how effective a drug is and the cost of the drug,” and becomes especially indignant when pharmaceutical-industry spokespeople suggest that any effort to contain drug prices will curtail innovation, calling it a form of “blackmailing” against the national interest. He’s pretty exasperated with his fellow oncologists, too. “In the last decade, we have become glorified employees of the drug companies,” he says.

Again read this and consider what we need to do not just to bend the cost curve but to deliver better patient care. In light of this article and the indictment of oncology drug pricing we need to consider what palliative care delivers and not solely on a cost analysis but a quality of life basis. Studies need to be done. I would like to see a trial to compare palliative care to cure and measure outcomes of both survival and Q0L. 

Pediatric Caregiver Attitudes Toward Email Communication: Survey in an Urban Primary Care Setting
Dudas and Crocetti published and original paper in JMIR. There have been much discussion regarding the usage of email communications between patients and HCP and how it will drive major change. The authors performed a survey to measure pediatric caregiver access to and attitudes toward the use of electronic communications. 

We hypothesize that parents bringing their children to a pediatric primary care clinic have access to the Internet and email and would be interested in communicating with their health care providers by these modalities. The aim of this study is to document pediatric caregiver attitudes toward and access to these technologies in an urban pediatric primary care clinic.

The authors concluded:

Caregivers of children in an urban pediatric primary care practice have access to email and would be interested in communicating with health care providers by this method. African-American caregivers and those in lower socioeconomic groups hold less favorable views toward email communication; thus, the use of email may exacerbate existing disparities in health care delivery. Future studies should examine the reasons for these attitudinal differences.

Why is the right question and do we have time to wait?

Awesome Video from the Children’s Hospital at Dartmouth-Hitchcock (CHAD)
The Healthcare Marketer shares this emotionally powerful video from Children’s Hospital at Dartmouth-Hitchcock. Tear alert… you will tear up. Powerful. Let’s get the number of views up. 

This has to be the idea from the agency because it works so well. Not your usual in house effort. And I am right the agency is Sublime Eye.  

Notes & Links: October 22, 2013

Six Frightening Facts You Need to Know About Healthcare

I saw this on my news reader and thought I would write about link bait. So reading Robert J. Szczerba contribution to Forbes made me stop and think shit healthcare in America is worse than the Health Exchanges web sites. I knew most of these facts from various sources But to see them in one place at one time is a WTF moment.Here is the list

  • Up to 400,000 people are killed each year due to preventable medical errors.
  • 765,000,000,000, or 30% of all U.S. healthcare costs, each year is wasted.
  • 33% of hospital patients suffer some form of preventable harm during their hospital stay.
  •  58% of clinicians felt unsafe about speaking up about a problem they observed or were unable to get others to listen.
  • Critical care patients each experience nearly 2 medical errors per day
  • 92% of U.S. physicians admitted to making some medical decisions based on avoiding lawsuits, as opposed to the best interest of their patients

Generally I would say this is a good read. Not so much, I am typing this from under the covers wrapped in bubble wrap so I don’t end up in the hospital.


Graphic novel well more tot he point Slate has 12 Panel Pitch which is an idea for a feature film boiled down to 12 panel. This is one is titled Radiant and is about the women who suffered at Radium poisoning during WWI.

Simply great

Chart: Euthanasia in Europe and the US

Austin Frakt got the chart those of interested in end of life care, hospice and palliative care, death with dignity etc. are dying to see.

Notes & Links: October 21, 2013

Yesterdays news today. Sorry but life got in the way of life.

Just How Bad Is That Federal ACA Health Care Exchange Problem Anyway

Tim Worstall, Contributor at Forbes hits us with the good stuff. This was written prior to the speech by Obama on ACA which for now I will allow others with an ax to grind to parse its meaning. Clearly the execution of this technology has failed. And it appears from this article and from Obama’s comments a lot of code will need to be rewritten. Worstall makes a great point and one that is at the core of this issue

It’s not just Java for the script kiddies, for sure, but the complexity is actually in the design, not the programming. That design should have been nailed down two years ago, the code written and then tested for a good 6 months. Rather than what actually happened, which was that the design itself was still changeable into September of this year. That those insiders are still misdiagnosing the problem shows quite how far out of a technical understanding they are. There is this:

This is a good article in light of Obama’s speech. But it is even more important when you consider this Poll: Majority believe healthcare website problems indicate broader issue with law.

Fifty-six percent of Americans say the website problems are part of a broader problem with the law’s implementation while just 40 percent see the website problems as an isolated incident.

The bungled rollout has not soured support for the health law overall, however. Forty six percent now support it while 49 percent oppose it. That compares favorably to a 42 to 52 percent negative split last month. 

Somewhere in this long painful road to healthcare in America is a Harvard Business School. I hope this ends with something more, better patient care, bending of the cost curve, improving outcomes, and just giving Americans a chance to live better

New Obamacare Numbers – Success Or Failure?
Dan Munro contributor at Forbes looks at the numbers from the state exchanges and talks about his experience applying. Today the administration said about 476,000 health insurance applications have been filed through federal and state exchanges. It remains a mystery on how many people have actually enrolled in the insurance markets. But to note a bit over half of those are from 36 states where the Federal Government is running the markets. The remaining half is from state run exchanges. 

Munro ends with this and keep in mind the ACA is the single biggest target on the presidents back and when those of a certain ilk are looking to be haters ACA/Obamacare is what to aim for. 

All of which suggests that rendering a success or failure verdict at this early stage (based almost entirely on the initial and poor performance of the public exchanges) seems premature. Either way, success or failure, one thing remains certain. We’re likely to see a lot more political math between now and the end of the year.

Study adds to growing recognition hat improving graduation rates can improve public health
The Pump Handle on Science Blogs has post by Kim Krisberg looking at new data showing that dropping out of high school increases the risk of illness and disability in young adulthood. Here is the open access to BMC Public Health here

Interesting to note that high school graduation was never singled out as a major public health objective. And the data clearly shows the link between morbidity and mortality. 

Among the results, study authors found that the risk difference for long-term sickness or disability between those who complete high school and those who drop out was 21 percent. And even after adjusting for the accompanying risk factors listed above the risk difference was still 15 percent. 

Krisberg shares some data regarding the US drop rate and the fact it has declined from 12% in 1990 to 7% percent in 2011 with rates declining among whites, black, and Hispanics. Now I guess the question becomes do we use a health strategy to drive getting a high school diploma or do we drive the message that a high school diploma will help you live longer? 

Notes & Links: October 17, 2013

Some more thoughts on shared decision making
Aaron Carroll writing in The Incidental Economist followed up on his previous post on shared decision making here. Carroll reviews a JAMA Viewpoint on  Shared Decision Making (SDM). 

He concurs that SDM informs patients and is something that must has to be done. And he further agrees that SDM creates a more satisfied patient. Where plumbs the depths of rational questioning is SDM does not equal cheaper patients. I am not sure there is definitive evidence that SDM does equal cheaper patients but Health Affairs had this study in February of this year. 

In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What’s more, patient activation was a significant predictor of cost even after adjustment for a commonly used “risk score” specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients’ ability and willingness to manage their health will be a relevant piece of information integral to health care providers’ ability to improve outcomes and lower costs.

Delaying Vaccinations
I have been following the comments from this post I did yesterday. Thought I would share one. This is how physicians flame.

Author: Sheldon Weisgrau Comment: Emily, vaccinations are among the most studied, well understood medical interventions (and along with sanitation, the most successful public health measures ever implemented.  Remember small pox and polio?  Neither do I.  That’s the point.) If you question vaccines, I wonder how you prescribe any medical interventions to your patients?


Notes & Links: October 16, 2013

How To Build An Effective Social Marketing Strategy
I’ve struggled to find or discuss with others the topic of social media and that we need a strategy not just tactics. Greg at Digital Tonto just published this post. Immediately what stuck me was the headline a Social Marketing Strategy, not a Social Media Strategy. Since the later is a tactic not a strategy. 

Greg’s primary message is simple, in our previous marketing lives we grabbed attention now we need to HOLD attention ergo social media.

Apple stands for design.  Harley Davidson stands for friendship and camaraderie.  Red Bull stands for an extreme lifestyle.  These brands successfully engage consumers because the brand’s mission supersedes whatever they happen to be selling at any given time.

Doh! Are providers doing that? Group practices? Solo practices? What they are doing is as Greg says running longer versions of their ads with all the resident features and benefits. He notes that we should perform the following:

So the best way to start formulating a social strategy is to identify others who share your mission.  What are they doing?  What succeeds and what doesn’t?  What can we add? What can we subtract?  There’s no reason to try to reinvent the wheel.

I agree 100% but would add my own one trick pony which is identify the problems your audience wants to solve. In healthcare that is find the problems you patients are seeking solutions to and you will become an analogue to that patient. HCP and providers are already trusted, well to a point, helping solve problems secures that trust better and more effectively.

Okay wait for it… wait….

The truth is that the strength of your community has much less to do with how consumers are connected to you than how they are connected to each other.  That’s how great social brands, like Apple, Harley and eBay built devoted followings long before anyone even heard of social media.

Boom! Not just social media but a strategy.

I wrote to Greg and he responded with the following:

Unfortunately, I’m going to have to disagree with you. I actually left out needs analysis on purpose. It’s very hard to separate it from consumer analysis and then you’re down the rabbit hole. When formulating social strategy, it’s best to stay mission focused. Needs analysis is important as well, but it can wait for execution.

I realize that in health care, it’s very hard to separate the two, but you should try. It will make you rethink how you deliver content, who you partner with, etc.

Surge Of Employer Health Exchanges Is No ‘Passing Fad’
Bruce Japsen a contributor at Forbes has some positive news about healthcare and health insurance. I am trying to calm my racing heart to create the link to it. So much throwing shade regarding ACA. 

His point is that many companies are contracting with private online marketplace exchanges to provide employees with subsidy or credits t purchase the coverage they want.

The private exchanges work with each employer in the exchange deciding on the subsidy or “credit” that each worker will get to purchase coverage offered by the employer. Then, the employees take to the private exchange to select their coverage. The subsidy will vary from employer to employer.

Still, the private exchanges do work like those that are expected to be operational by states or the federal government next month under the Affordable Care Act next year in that they offer consumers more choices plus people who buy coverage are empowered to make choices for their individual needs, benefits consultants say. Open enrollment for uninsured individuals under the health law begins Oct. 1 and runs through next March.

This is good news and speaks to a type of free market where the consumer gets to participate in the purchase.This fits with data that shows consumers/patients are significantly more active in becoming ePatients regarding their healthcare. With small steps a journey begins. Let’s hope this is not off a cliff.

Why Is It So Hard To Predict Sales Of New Drugs?
Another Forbes piece by contributor John LaMattina kinda let’s us know that even big, smart, powerful, all knowing pharma put their pantyhose on one leg at a time. These are the smartest men & women pushing a beaker around. Yet?

LaMattina reviews the article in Nature Reviews by Cha, Rifal, and Sarraf Pharmaceutical forecasting: throwing darts? So if they are so smart why?

  • Missed understanding of market potential and fact market would be expanded
  • Where effective treatment of ED did a number on the market to the tune of 4x the original prediction
  • Lipitor’s potency was not considered to be so unique, well throw that out the window
  • Orphan drugs can become blockbusters

LaMattina offers his view that physicians and payers are driving some drug prices which makes this whole prediction thing even more dart like. From my perspective the greater the role of patients move toward ePatients and having an active role in their health with their physicians and their fellow patients this will put not only pricing pressure on the prediction question but on the success question. Will a drug be successful before it is widely used.

Some more thoughts on shared decision making
Aaron Carroll writing in The Incidental Economist followed up on his previous post on shared decision making here. Carroll reviews a JAMA Viewpoint on  Shared Decision Making (SDM). 

He concurs that SDM informs patients and is something that must has to be done. And he further agrees that SDM creates a more satisfied patient. Where plumbs the depths of rational questioning is SDM does not equal cheaper patients. I am not sure there is definitive evidence that SDM does equal cheaper patients but Health Affairs had this study in February of this year. 

In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What’s more, patient activation was a significant predictor of cost even after adjustment for a commonly used “risk score” specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients’ ability and willingness to manage their health will be a relevant piece of information integral to health care providers’ ability to improve outcomes and lower costs.

Delaying Vaccinations
I have been following the comments from this post I did yesterday. Thought I would share one. 

Author: Sheldon Weisgrau Comment: Emily, vaccinations are among the most studied, well understood medical interventions (and along with sanitation, the most successful public health measures ever implemented.  Remember small pox and polio?  Neither do I.  That’s the point.) If you question vaccines, I wonder how you prescribe any medical interventions to your patients?


Notes & Links: October 15, 2013

Delaying aging to bend the cost-curve: balancing individual life with societal costs

Jane Sarasohn-Kahn writing on her blog HealthPopuli speaks to a complex issue facing us in healthcare what happens when we delay aging or age more slowly. She takes a deep dive into an article in Health Affairs Substantial Health and Economic Returns from Delayed Aging May Warrant a New Focus for Medical Research

Sarasohn-Kahn provided a chart from a 1997 Rand Corporation Future Elderly Model. Like all good charts it says it all. 

If delayed aging is indeed a real possibility in humans, the economic question for the end-game (literally) is: can society’s economy afford to extend lives? Living longer could lead to people taking on a huge disease burden at the end of life, suffering multiple lethal issues for the health system to deal with both clinically and economically for Medicare. In addition, people who live longer lives would also add to the Social Security program demand for income support.

This is another look at cost and health one that we need to consider and not kick down the road. The key word here is bending the cost curve and that must be done.What is the balance between bending a curve and breaking a patient?

Tips For Medicare’s Tricky Open Enrollment Season

Caroline Mayer a contributor to Forbes has some handy tricks for medicare open enrollment season. This is rich resource of information and references those of us at a certain age can use. This is especially true today with ACA and the current shutdown. The article addresses:

  • Website issue (thank you Congress)
  • Medicare Enrollment Scams
  • Changes in Medicare Plans in 2014
  • Medicare Enrollment “Don’ts”
  • Medicare Open Enrollment “Do’s”

I would add to this a non-profit organization that helped my wife a couple of years back and who were so helpful and supportive. Medicare Rights Center.

This is a good time to review, consider, review, and act. Being an ePatient means never having to worry about your insurance because got e’d about before signing on the dotted line.

Delaying Vaccinations is Stupid

Aaron Carroll on The Incidental Economist jumps on the delay childhood vaccinations cohort with a strongly worded well referenced post. The data he presents is from Delaying Vaccination Is Not a Safer Choice from JAMA Pediatrics and is behind a pay wall. 

Parents delay vaccines because they worry about too much at one time and the poor little ones bodies can’t handle them. Here is just one section from Carroll’s book Don’t Cross Your Eyes… They’ll Get Stuck that way and Other Health Myths Debunked

In a manuscript specifically designed to answer this question in the journal Pediatrics, Dr. Paul Offit and colleagues estimated that infants likely have the capacity to respond to about 10,000 vaccines at any one time.  No vaccine could “use up” the immune system.  In fact, estimates showed that if a child received 11 vaccines at one time, that might occupy about 0.1% of the immune system.  You’d never notice that.

Carroll’s post is clear, concise and should be a reference URL for any of us who want to support delayed vaccinations with fact, science, and evidence. Hop over and take a look.

Takeaways From Standford Medicine X Conference

Casey Quinlan posting on HealthWorks Collective gives us an up close and personal look at this years Stanford Medicine X. She was tagged as an ePatient Scholar. The URL contains her review and three videos. 

Here is her closing thought

What did I learn at MedX? I learned that there’s hope. Hope for healthcare, hope for humanity, and hope for every single person who winds up a patient (and hey, we’re all patients, right?). The key is that medicine is a team sport. It requires the full participation of everyone in every health-related 

Great post with valuable links and insightful videos.

Notes & Links: October 14, 2013

Trust is What Makes Health Care Work – A Success Story From Belgium
Steven Shie writing at Thoughts from Broad Street captures in couple of simple clear sentences what the problem is in our healthcare system and the solution. He share with reads a lecture by Dr. Florence Hut physician in chief at Brugmann University Hospital.

If the Belgian health care system is any indication, the answer to fixing the U.S. health care system may not be tactics but a new perception of health care that is built upon mutual trust and humanity. Because when trust and humanity are gone, we see serious issues that negatively affect everyone in the system: defensive medicine, low efficiency, poor outcome, alarming safety records and most of all, the indifference for those who rely on safety net for care in a country where so many strongly believe “personal responsibility” and free market are panaceas.

Last night during the #hcsm chat one Topic 1 was –

HC needs changing, and so do HC orgs. If you could lead any HC org, which would you lead; what would you change and why?

The answers were far ranging and smart if not heart felt. 

  • would lead a private office doing DPC (direct pt care) & take care of patients the way SoMe has taught me over the last 2 yrs
  • I would lead the NCI, and start by enlisting patient panels across each aspect of the agency’s work
  • Start with the simpler stuff like making clinical trials understood by lay people…no more clinical lingo
  • If I expand to anything, I would agree either NCI, or an Insurer. To drive change today, start w reimbursement & rest will follow    

Dr. Hut is right as rain. No tactic will make a difference. It is about trust, mutual trust and respect for the humanity of healthcare. Those Belgian patients trust their HCP and they company (the goverment) with managing their healthcare. With those Americans attacking healthcar, behaving healthcare is a privilege not a right, and throwing shade at every juncture and mention it is no wonder we as a people are confused and distrustful of our system and there are no amount of chats, social media, patient engagement that can overcome the basic flaw: we don’t trust the system, our HCP, what we read, hear, see, etc. The small point of light that may help create trust are the millions of Americans who are seeking knowledge about their health and the DIYhealth movement may make a difference at the individual level. But it must be a mutilfaceted exercise of HCP, patient, provider, etc etc. 

Shie’s piece is short, smart, and full of good data we can all use. Worth the read.

Social Media in Medicine: Interview at Medicine X
Bertalan Mesko is interviewed at Stanbford Medicine X 2013. It is a short 5 minute interview but filled with understanding of what the needs of this new healthcare world we are entering. 

Mesko is so correct when he says “I believe it’s about medical communications not social media.” We can’t forget that adults learn when they seek solutions to problems and when those answers are clear, concise, and fit with the learners needs (i.e. communicates clearly).

When Talking About the Exchanges, It’s Probally a Good Idea to Look Beyond Opening Week Returns
David Dranove & Craig Garthwaite writing on The Health Care Blog gives us all some good advice, stop, take a deep breath, and step away from the Exchanges opening week returns. As we all know but just to repeat like any other web site hits must become registrations and we can’t end up having the 20% sickest Americans representing 80% of the enrollees.