ACA Then, Now, and Tomorrow. Measuring Success or Failure.

New Web Site. New effort. Old news updated. The ACA then and now.

I was looking at my archives and found Notes & Links: October 21, 2013. I posted a piece that Dan Munro a healthcare contributor at Fobes had on Obamacare Numbers Success or Failure? Munro noted that there were 476,000 health insurance application were filled through ACA Federal and State exchanges. Since then we can say a few more Americans have applied with over 20 million people have health insurance either through public o private options. As of December 24, 2016 there were 11.5 million people who used the federal marketplace to buy health insurance. 8.9 million renewed their coverage or bought new plans to replace existing plans. 2.6 million new people enrolled. It was so cute that Munro ends that piece from 2013 noting that the ACA is the single biggest target on Obama’s back. You think.

Fast forward to Munro article in Forbes Trump Acknowledges That The ‘Replacement’ Of Obamacare Will Span Years. This was pulled from President Trumps interview with Bill O’Reilly. Besides the fact Trump is seeing that the ACA can’t be just turned off without doing great harm to millions of Americans. Ultimately in rich and ironic way the GOP is being forced think about outcomes that are not tied to punishing former President Obama. GOP oh my. Which brings me to my final thought here.

As the ACA is repealed, replaced, or repaired there will be reams of pages written about the harm these actions will have on the sick, the old, and the young. There will be competing projections of what these changes will produce. For now the little we know about what will be done or considered is not enough to get our outcomes arms around.

I would like to imagine that someone, some academic institution, some group of thinkers will set up a site to track key healthcare outcomes retrospectively from the beginning of the ACA to its ‘repair’ and then going forward. Surely there will be measures of those who have and don’t have health insurance and measures of cost of health insurance and more. I am hoping we can get into the granular data that may takes years to revel a trend.

Just to throw out some ideas: Measure standards of care treatments and their outcomes for specific conditions. Compare Repaired ACA to Pre-Repaired to Non-ACA health insurance. Will we see worse outcomes in one group vs. the other group?. Are treatments offered as first line differ between measured segments? Is the life expectancy for similar diseases and patients shorter or longer between segments?

I am not a statistician nor an epidemiologist (obviously). So I’m not sure any of this can be done. Should it be done? Yes, because this is the type of evidence (not alternative facts) that the fix and repair GOP made into law. We need to know if it’s keeping Americans alive and healthy. This GOP driven destruction of Americas health is similar to the Death Panels feared in 2012 by the GOP. Now they get to enact their dream, thinning the herd of poor, sick, and non-GOP voters.

Bonus link, One World In Data. Really great charts and graphs on healthcare.

Our World in Data
Life expectancy vs. health expenditure over time 1970-2014

Notes & Links: October 4, 2013

Assessing the Internal and External Validity of Mobile Health Physical Activity Promotion Interventions: A Systematic Literature Review Using the RE-AIM Framework

This is good less from the study and more from the fact the authors have demonstrated that we can review and critical appraise mobil apps. It’s hardly perfect but it is a step in the direction of helping patients and HCP know what works and what doesn’t. 

Blackman, Zoeliner, Berrey, et. al writing in JMIR have performed a Cochran Review on mobile apps. This is fascinating from the simple fact it begins to establish a methodology to review mobile apps for physical activity. 

Despite the popularity of commercially available health-related applications, there is little evidence that mobile phone-based interventions with demonstrated efficacy have been translated beyond the research setting and been broadly adopted [19]. Some potential reasons for the lack of translation of these interventions into more widespread use are that the scientific approach typically emphasizes high internal validity at the expense of external validity [20] and that the traditional research pace impedes the flow of disseminating relevant findings [21]. To date, reviews of mHealth interventions have evaluated the quality of studies through the lens of internal validity and emphasized improved reporting on potential confounding factors [22]. As a result, the conclusions are largely limited to factors related to intervention efficacy and the extent to which these mHealth interventions report on or achieve external validity to different settings and populations is unclear [1317,23]. 

This study used RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) to inform investigators who will do research on mHealth applications. This is the first I’ve seen on standardizing how we determine the value across a broad measure for mHealth applications. They also clearly show current limitations and where we as an industry need to improve. Mobile health applications are becoming the center piece to our healthcare in many regards. Also we know that they are bought, downloaded, and frequently forgotten about. Using RE-AIM along with other metrics can help determine the clinical value of apps and how to design better one not only from a shinny toy with bells and whistles perspective but from a patient outcome point of view. This sorely needed. 

The authors conclude

There is an emergent body of literature reporting on mHealth PA interventions. On average, the studies provide initial evidence that these interventions may have promise in helping participants initiate PA. However, few studies report on key internal (eg, delivery as intended) or external (eg, descriptions of participants, settings, and delivery staff) factors. As a result, the degree to which these findings are robust and generalizable cannot be determined. Improved reporting across RE-AIM dimensions and the use of intention-to-treat, tracking of costs, and mixed methods approaches are recommended to ensure mHealth PA interventions are developed that can be broadly applicable across target populations, intervention delivery locations, and staff of differing levels of expertise.

Health care in the USA hanging in in the balance
The Lancet offers some editorial insight and comment on healthcare in the US of A. The editorial is an excellent review of Obamacare with no hyperbole and written simply in plain Queens English. I am sure from their vantage point they are missing all the hairs growing out of each ACA wart. This is a great easy read to wrap your head around. 

The closing paragraph offers insight on what the world sees.

What is clear is that, even under optimal conditions, the health insurance marketplace is a work in progress, involving the commitment of thousands of civil servants, administrators, consultants, programmers, and, ultimately, consumers. As part of risky manoeuvring to extract political concessions, gutting the ACA and scrapping the state exchanges is an irresponsible and short-sighted assault on the promotion of the health and wellbeing of Americans. Irrespective of meeting arbitrary deadlines, the efforts of these individuals converge on the vital goal to overhaul the health-care system in the USA. Health-care reform is a process that must start somewhere and will adapt and evolve over time. The ACA offers that starting point—there should be no turning back now.

Vaccine Conspiracy Theorists More Likely To See Conspiracy Everywhere
File this under the biggest tin foil hat wearers are the vaccine conspiracy theorists. Leaders of the pack. I am of the age I still think there was a shooter on the grassy knoll but, I am not grabbing huge real estate on the Web to drive my theory. 

Emily Willingham a contributor to Forbes gives a nice review of current thinking about vaccine conspiracy theorists and specifically autism. She notes research results from PLOS ONE that found conspiracy theories are lock stepped with a rejection of science. The authors also find that vaccine conspiracy theories have a political flavor and fit libertarian leanings and those not as conservative reject immunization because of the pharmo industrial complex. Who can trust anyone that sell a drug proven to be equal to placebo?

Least we forget there are health consequences to the continued vaccine-autism conspiracy crap. It harms others and the child. The woman who was killed in Washington DC had her 1 year old daughter in the car. Some have said that she put that child in direct danger and harm. Not vaccinating does the same. 

What can we do? Not much. 

Lewandowsky and co-authors close their paper almost dejectedly, noting that because “conspiracist ideation” leads believers to resist evidence contrary to their conspiracy theory, presenting them with scientific evidence tends to amplify that rejection. They recommend affirming the competence and character of the conspiracy theorist and kind of leaving it at that. Please, consider yourself affirmed.

Not so much it seems. But we can not let those to are anti vaccination not drive the message or control the voice online. Reason and science must prevail since we are seeing outbreaks of measles, mumps, etc. 

Notes & Links: August 2, 2013

Read the Fine Print Before You Burn Your Obamacare Card

A guest post by Aaron Carroll on The Incidental Economist speaks to the conservative organizations pushing young adults to skip joining ACA and pay the penalty. 

People pushing young adults to skip the exchanges aren’t saying, “Don’t enroll now… but hey, if you get sick in a few months, we’ll understand if you have a change of heart.” They’re saying, “Don’t enroll now; pay the penalty instead. And if you fall ill, or become pregnant, or get stabbed while doing a good deed and you can’t buy a plan, well, them’s the breaks. That’s the gamble we asked of you.”

Some of these young adults must have seen their parents loose jobs, loose coverage, loose their homes, and life without healthcare coverage. I would think that is enough motivation to want healthcare insurance. It would be for me. I know when I had a bunch of employees working for me I made sure healthcare insurance was offered at a great price and for many many years with no employee contribution. I believed in its value. Hopefully these young adults see the value as well. We’ll know soon enough. 

Countdown to The Physician Sunshine Act: Gloomy Days Ahead

Jonathan Govette posting on HealthWorks Collective speaks to the Sunshine Acts and its August 1, 2013 start of data collection. The title kind of says it all about his position and attitude. And the site is sponsored by Siemens a medical device manufacturer. 

So basically every doctor in the country will now have to report his private financial information to the world.  Seems like this is a complete waste of time and will cause more harm than good.

I would agree about flashing personal income all over the web. But these are payments that have been well documented and associated with prescribing and often not associated with evidence based medicine or the best Rx for that patient. Patients and colleagues should know what the financial association with pharma or device manufactures are. That’s why they call it transparency. 

Sunlight as Disinfectant

Professor Meredith Rosenthal Ph.D. and Michelle Mello, J.D., Ph.D writing in the NEJM have a much better and more salient review of the Sunshine Act and its benefits vs. the problems. They capture two key point here:

Disclosure rules aim to influence the behavior of both the subjects of reporting and those making decisions about whether to do business with them. Thus, one mechanism through which the Sunshine Act could reduce health care costs is that patients, having learned of a physician’s involvement with industry, might alter their view of the physician’s trustworthiness. They might be less inclined to accept treatment recommendations from these physicians or even to receive care from them. Given the evidence that greater physician financial involvement with manufacturers is associated with higher utilization of expensive, brand-name products, such dynamics could reduce costs.

Experience gives reason for skepticism about the potential force of patients’ response to disclosures, however. Decades of public reporting of provider quality information have underscored the difficulty of engaging consumers in seeking even the most salient information about their providers, such as a cardiothoracic surgeon’s predicted mortality rate, from a passive report.3Consumers are typically unaware of these data and, even when they know about them, tend to choose their providers on the basis of other factors. The payment data are also complex, and even with the educational information CMS plans to provide, patients may have difficulty evaluating the undesirable and beneficial aspects of various types of payments.

Read both articles and see which one rings as a true well balanced examination of the Sunshine Act and which one is grinding a whinny ax?

Spike Lee Shares His NYU Teaching List of 87 Essential Films Every Aspiring Director Should See

Thanks to Doc Searls for this link. I would love to be an aspiring director but I am more of a film freak so I wanted to see what was on his list. I’ve seen 62 of the 87 and need to revisit most of them (memory sucks) besides what I haven’t seen. Guess me and Netflix will be busy this year.

You Don’t Have To Be A Data GeekTo Love Consumer Health Devices—But It Helps

David Shaywitz writing on writing about capturing health data from phones, devices, and apps. I think for some of us he captures what and why for these devices 

In other words, my gadgets don’t provide essential information I couldn’t get elsewhere, but they motivate me to pursue and sustain activities I might otherwise avoid – like regularly checking my blood pressure, or finding time for a run.  They facilitate data sharing, whether with my doctor, as I’ve described, or with friends and family who can offer encouragement and motivation

I agree because on my bike I have a HR monitor and a computer to capture speed, cadence, max and average speed. I just love the data and comparing one ride to another. I no longer make a spread sheet with it. Maybe I will start again. But the bigger question is who are the others that capture data? What do they do with it? Do they share it with their physician? To what end?

We need to know more about the new world of consumer data. 

Hamptonites Are All Smiles Over Newest House Call

For the fee of $999, more than double what it costs for services in their office, the husband-and-wife dental team of Dr. Jeffrey Rappaport and  Dr. Michelle Katz will perform professional teeth whitening in the comfort of a client’s living room.

The only thing that comes to mind here is “Qu’ils mangent de la brioche“. But we live in a free market for some.

Notes and Links: September 18, 2013

How Circumcision Broke the Internet
Mark Joseph Stern writing in Slate has a terrific and sobering review of circumcision data online and how it is horrifically biased with the tinfoil hat crazies. 

Stern points out that if you go online and search for facts about circumcision you end up “assaulted by a vitriolic mob of commenters accusing the author of encouraging “genital mutilation.” The self proclaimed anti-circumcision group call themselves “intactivists”. They argue mutilation, human rights, reduction of sexual pleasure (how your foreskin will give you a life of satisfaction and joy), circumcision is equal to female genital mutilation, etc. etc. 

The problem with these arguments is that they’re either entirely made up or thoroughly disproven. None of intactivists’ cornerstone beliefs are based in reality or science; rather, they’re founded in lore, devilishly clever sophistry dressed up as logic. The facts about circumcision may be hard to find on an Internet cluttered with casuistry—but they are there. And they prove that even as intactivists dominate the Internet, the real-world, fact-based consensus on circumcision is tipping in the opposite direction.

Take, for example, the key rallying cry of intactivists: That circumcision seriously reduces penis sensitivity and thus sexual pleasure. Study after study after study has proven this notion untrue. Some men circumcised as adults actually report an increase in sensitivity, while many report no appreciable difference; virtually none noted any notable decrease. Men circumcised as adults also almost universally report no adverse effect in overall sexual satisfaction following the procedure. (That fits with what my colleague Emily Bazelon found when she asked readers for their circumcision stories a few years ago.) And genital sensitivity in response to erotic stimulation is identical in circumcised and uncircumcised men. Don’t trust individual studies? Asystematic review of all available data on circumcision came to the same conclusion. Intactivists, then, aren’t disputing a few flimsy studies: They’re contradicting an entire field of research.

The article goes on about how a few have taken control of an important decision. What is striking is how a group with an agenda can dominate the Internet in such a way that good science and evidence based data is difficult or impossible to find by the average parent. And the fact these  “intactivists” drive the search results they play off of parents fears at a critical time, pregnancy when clear thinking is not in the forefront of gestation. 

Those of us active in healthcare on the Internet will debunk false claims of pharma and tout the benefits of the Sunshine Act and taking pharma out of the HCP’s office but where are we when an anti-circumcision mob is hijacking science and evidence? 

Palliative Care and the Human Connection: Ten Steps for What to Say and Do
Diane E. Meier, MD is the Director of the Center to Advance Palliative Care (CAPC). I have recently discovered the above linked video and it is excellent. It speaks to the medical professional but has information that we can all benefit and learn from. It is one of clearest and most compelling discussions on this topic I have seen or read. Of course this is Dr. Meier and she knows her stuff as well as anyone on earth. I cannot recommend this video enough. Just a couple of gems from it:

  • 70% of human communication is non-verbal (Donna’s oncologist demonstrated this with his discussion). And to add to that it is part and parcel of what I want to do with the film “Care When There is No Cure“. 
  • You place the power of how the person wants to receive information in the hands of the patent 

The iPhone 5S and 5C
Jon Gruber at Daring Fireball has an excellent and detailed review of the two new phones from Apple and key features including: 64 bit processor, Touch ID, the camera, and more. As usual one of the better tech writers drives a clear and well balanced message. I guess linking to John makes me a bit of fanboy but take a look at Walt Mossberg’s review of the iPhone 5S which ecohs John’s thoughts as well. And Laura Goode reviewed the iPhone 5c

My question is this how are the Apple Stores going to display and demonstrate Touch ID? I can’t imagine customers coming in and locking all the display phone with their finger pint and leaving. How crazy would that be? Entering a password is old school everyone wants to use their fingerprint. 

20 Things 20-Year-Olds Don’t Get
Jason Nazar a contributor at Forbes has a great list of to-do’s for 20 year olds in business. They ring so true as I squint my eyes and look back 30+ years. Right now I am between consulting jobs, trying to identify the next business I want to open, or just throw the towel in. Whatever I figure out shortly is going to be driven by the fact that those of us of certain age are considered old, broken, and expensive. But when you consider someone has to list for 20 year olds how to act and what to do in business it eye opening. It tells me that as someone said “If you think you are getting a bargain hiring a 20 year old just think how much it will cost you to fix their mistakes.” 

I don’t want to get into a generational fight here but the reality is that cost savings vs. value is not equivalent. Employers need to see beyond short term gains and look at long term strategies which a 20 year old is lacking just from being 20.

Not Quite Ready for Prime Time: The State Health Insurance Marketplaces and Google
Elaine Swift and David McCormick writing at The Health Blog address an salient issue for success of Obamacare. 

Poor search engine results can create serious barriers to shopping and enrollment, the major measures of success for marketplaces and, by extension, the success of the Affordable Care Act (ACA).

Our preliminary findings show that marketplaces for four states—Idaho, Maryland, New Mexico, and New York—and Washington, DC did not appear on the first page of Google results, which generates 92% of all page views.  In addition, both unpaid and paid search results for most of the remaining 12 states were frequently absent from page one.

With enrollment in the marketplaces opening October 1 for coverage beginning January 1, this would be a good time to focus on search engine optimization (SEO), the process of increasing the rankings of unpaid or “organic” search results. Once implemented, SEO results can be seen quickly, especially for a topic as popular and important as new health insurance options. However, it requires analysis, planning, and time to implement.

The authors present an excellent table of all unpaid and paid search engine results. And it shows that page 1 results for marketplaces for Idaho, Maryland, New Mexico, New York, and Washington, DC and limited for other state marketplaces. 

Their advice, we need to get our act together to improve search results though they readily say it might be too soon since search engine optimization (SEO) may not have started. From my perspective besides making it easy to find we need to have broad discussions online about exchange marketplaces and how to find them what to look for. We need to help the average user improve the find of results so they can get the healthcare insurance they need and want. 

Notes & Links: August 21, 2013

How Obamacare Will Harm Cancer Patients

Scott Gottlieb, MD contributor to Forbes has a rather lengthy analysis of Obamacare and how It will hurt cancer patients. Dr. Gottlieb goes into great detail to make the point. 

 First, Obamacare is going to block the ability of patients to seek out the specialist doctors who are most likely to prescribe these cutting edge treatments.

Obamacare tries to coerce doctors to cut down on their use of costlier drugs and tests by changing the way that they’re paid. The law uses “bundled” payments, where doctors get lump sums of money to care for patients with particular medical problems. The idea is to pit the cost of the treatments doctors prescribe directly against their earnings and give doctors a potent incentive to use cheaper remedies.

Obamacare targets cancer drugs directly, by expanding a program called 340B, which siphons money away from drug developers in order to subsidize hospitals. The Obama Administration sees the program as a way to prop up the hospitals (a favored constituency) on the dime of less popular drug makers. But the oblique way the money is extracted from drug companies spawns a lot of harmful consequences that are increasing the cost of cancer care, and lowering its quality.

Gottlieb further makes the case that over 20 years total spending on cancer care was stable at 5%. And further how inpatient cancer admissions fell from 64% in 1987 to 27% in 2001 to 2005. 

His closing thoughts are focused on the cost of cancer drugs and the high cost of developing thuds drugs. 

Instead, Obamacare limits access to specialist doctors in order to cheapen insurance products, uses financial schemes that pay doctors more to do less, and targets the drugs that represent so much of our recent progress against cancer.

I agree with this thought and logic but I am not familiar enough with the 1,220 pages in the law to debate the overall message he is presenting. And I would trust his logic and data but I must say the conservative press has picked up on this and is running like crazy with the headline and not looking at the message of cost of drugs. If anyone out there has more information on this please share.

Use of Twitter Among Local Health Departments: An Analysis of Information Sharing, Engagement, and Action

Neiger, Thackeray, et. al from Brigham Young University Department of Health Science publishing in JMIR examined how local health departments (LHD) used Twitter to share information, engage with followers, and drove action behavior. In addition they looked at differences between LHD’s by size of populations served. 

While some evidence suggests that broad dissemination of information characterized by traditional mass media campaigns can improve population health, effective campaigns require simultaneous availability of and access to programs, services, and products that facilitate change [29]. Furthermore, broad dissemination of information ignores the fact that messages should be targeted to the intended audience. In the case of Twitter, LHDs may know nothing or very little about their followers unless they engage in dialogic communication to establish relationships. To indiscriminately post information on Twitter is inefficient. In fact, this contributes to what has been described as a fractured and cluttered media environment that can be resolved only through careful planning and testing of campaign content with intended audiences [29].

It was encouraging that at least one-third of LHD tweets attempted to engage followers, foster relationships, create networks, or build communities. These results are similar to those found by Lovejoy and Saxton in their analysis of how nonprofit organizations use social media [10]. Use of personal pronouns was present over a third of the time and more common among smaller LHDs. Additionally, evidence of effort toward dialogic communication included tweets that tended to be conversational in nature and may have used personal pronouns but were not necessarily intended for the purpose of engagement. This evidence of more conversational posting indicates LHDs may be trying to create a Twitter persona that is warm and friendly, thus making it more inviting for Twitter users to follow.

Are we beginning to see the fruition of social media (i.e. Twitter) in healthcare providing a welcomed and valued dialogue with health departments that improve the health of populations? I hope this data is only the start. 

Usage of a Generic Web-Based Self-Management Intervention for Breast Cancer Survivors” Substudy Analysis of the BREATH Trial.

van den Berg, Peters et. al from Radbound Rniversity Nijmegen Medical Center in the Netherlands publishing in JMIR have a fascinating and important look at how generic Web-sites are used and can be better designed for breast cancer survivors. This is an important study in my view because we are beginning to look at patients as learners based on usage statistics. This is providing ‘realistic estimation of exposure to intervention content“. Further the authors note “results suggest that investigating how generic fully automated Web-based interventions are used is far more informative than the amount of exposure. Usage statistics should be chosen accordingly.” 

 This is an important a first step. I believe we need to look at how these survivors are using this information to learn and what problems they are seeking to solve. 

The stated objective 
To gain insight into meaningful usage parameters to evaluate the use of generic fully automated Web-based interventions by assessing how breast cancer survivors use a generic self-management website. Final aim is to propose practical recommendations for researchers and information and communication technology (ICT) professionals who aim to design and evaluate the use of similar Web-based interventions. 

This study underscores the added value of evaluating usage statistics of generic Web-based interventions as a realistic estimation of exposure to intervention content. To the best of our knowledge, the present study gained first insight into the design of technical usage evaluations of generic fully automated Web-based interventions. Overall, and in concordance with research on more interactive eHealth applications [38], results suggest that investigating how generic fully automated Web-based interventions are used is far more informative than the amount of exposure. Usage statistics should be chosen accordingly. Further, it is recommended to collect both singular and composite usage statistics, include self-reported usefulness, and to pilot test a variety of usage statistics to aid decision making of meaningful usage parameters. Last, shared knowledge about ICT and conducting research is helpful in developing a meaningful rationale of technically recorded usage statistics of generic Web-based interventions.

Notes & Links: August 12, 2013

How Obamacare Affects You has a simple easy to read info graphic on Obamacare. An interesting fact about the ACA that really speaks to the complexity of healthcare in America.

It is twice as long as the Defense Authorization Act of 2010. The entirety of U.S. code is 45 million words making H.R. 39620 0.5% of all U.S. Code!

It is easier to go to war it seems. 

Americans Don’t Understand Insurance, Let Alone Obamacare Research Shows

Bruce Japsen contributing to Forbes presents some surprising data on Americans knowledge of Health Insurance.

“Researchers looked at two surveys of Americans between the ages of 25 and 64 who have private coverage.  Among their findings, researchers uncovered that just 14 percent of respondents had an understanding of the most basic insurance concepts of “deductible, copay, co-insurance and out-of-pocket maximum.”

All the more reason we need to spread the word on the excellent info graphic on Obamacare linked above. Just as more and more Americans are using the web to learn about their health and become active participants the need to understand and make decisions about health insurance will make a difference. 

Americans’ Health Insurance Illiteracy Epidemic-Simpler is Better

Jane Sarasohn-Kahn writing on her blog HealthPopuli is addressing the issue of our understanding of health insurance with an excellent review of new research by George Loewenstein from Carnegie Mellon Published in Journal of Health Economics.  

Here is a sample of a chart from that study and it is speaks volumes about what we don’t know and need to know.