How cold was it in the Heartland? Headline:
Fargo man finds refuge from bitter cold in a freezer, where 'there's no wind chill'.
Tuesday, January 7, 2014
7:09 AM
Unknown
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Robert Pear at the New York Times offers a clear summary of a recent report by civil servants at the Medicare agency: "National health spending grew slowly for the fourth consecutive year, increasing 3.7 percent in 2012 to $2.8 trillion."
“The relatively low rates of growth that we’ve seen over the last four years are consistent with the historical trends that we’ve seen when we look at health spending and gross domestic product,” said Aaron C. Catlin, an economist and co-author of the report. “It’s consistent with what we’ve seen in post-recessionary periods in the past.”
Nonetheless, the Administration was all too quick to jump in with its interpretation:
[T]he White House said the data vindicated President Obama’s health care policies.
“The years 2009 to 2012 saw the slowest growth in U.S. health care expenditures since the government started collecting this information in the 1960s,” said Jeanne M. Lambrew, a health policy coordinator at the White House.
“While there is a debate about how much the Affordable Care Act has contributed to this health cost slowdown,” Ms. Lambrew said, “there is no doubt that it reduced Medicare spending growth, and most experts believe that Medicare savings spill over into the private sector.”
Most experts? None that were quoted by this excellent reporter. In fact, Medicare spending in 2012 grew faster than overall spending, at 4.8%. Recall that the 3.7% total growth in spending includes the Medicare amount, so everything-but-Medicare grew at a rate well below Medicare. (Medicare represents about 20% of national health spending.)*
Oy. Why do they feel they have to claim credit? As noted:
Some provisions of the new health care law increased spending and others reduced it, but the overall effects on spending were modest, said Anne B. Martin, an economist who was the principal author of the report. She estimated that the law had increased national health spending by a cumulative total of one-tenth of 1 percent from 2010 through 2012.
Read on:
Spending on hospitals and doctors increased at a faster rate in 2012 than 2011, while spending on prescription drugs and nursing homes grew more slowly.
Hospital care increased 4.9 percent in 2012, compared to 3.5 percent in 2011. Spending for doctors’ services and outpatient clinics grew by 4.6 percent in 2012, up from 4.1 percent in 2011.
"Spending for prescription drugs grew just four-tenths of 1 percent in 2012 compared to 2.5 percent in 2011." Why? "Numerous brand-name blockbuster drugs — most notably Lipitor, Plavix and Singulair — lost patent protection in late 2011 and in 2012 and generic versions became available. Generic drugs accounted for 77 percent of all prescriptions filled in 2012, up from about 70 percent in 2011."
You just have to look at the chart above to understand that there are cycles in the rate of change of health care spending. For an administration to claim credit for a dip in the rate is simply an exercise in over-reaching. It also makes that same administration responsible for any upward tick as the ACA goes into full swing. I don't imagine we'll hear much from them on that at this time next year.
Speaking of next year, why does it take over a year to compile these figures? Why are we looking at 2012 numbers? The bills for 2013 will be paid by February. Let's see if we can get these reports to be more current, so there is less tendency to "drive using the rear view mirror."
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* Also, recall that Medicare spending has two components. One is utilization, which is driven by demand. The other is price, which is set administratively--irrespective of the actual costs of delivering services. It is important to know the relative weights of the two factors when looking at overall changes.
- 2:31 AM
- Unknown
- No comments
An excellent political cartoon by Tom Toles at the Washington Post, consistent with my post entitled "Stupid and Cruel, both," published last May.
My thoughts at the time:
One of the signs of political sickness in America is the degree to which some Republican governors, apparently out of sheer spite for President Obama, have decided to be both stupid and cruel to citizens in their own states. I refer to those governors who have chosen not to permit their Medicaid-eligible residents to participate in the federally funded health care insurance subsidies under Obamacare (aka, Affordable Care Act.)
Whatever you think about the rest of the law, something is seriously wrong when governors are intentionally creating an uninsured underclass in their states.
My thoughts at the time:
One of the signs of political sickness in America is the degree to which some Republican governors, apparently out of sheer spite for President Obama, have decided to be both stupid and cruel to citizens in their own states. I refer to those governors who have chosen not to permit their Medicaid-eligible residents to participate in the federally funded health care insurance subsidies under Obamacare (aka, Affordable Care Act.)
Whatever you think about the rest of the law, something is seriously wrong when governors are intentionally creating an uninsured underclass in their states.
Monday, January 6, 2014
- 5:13 AM
- Unknown
- No comments
Flu Near You is a free and real-time online surveillance system administered by Healthmap, a research group at Boston Children’s Hospital. This year we are recruiting people from Massachusetts for a next-generation study that will revolutionize infectious disease prevention and awareness by making it community-based and data-driven.
Who can participate: Anyone who wishes to take a proactive and data-driven approach to improve their own health and that of their household and community members.
What participants will do: Eligible participants who log in and report symptoms weekly using our website or mobile app will get a Do-It-Yourself flu test kit and a saliva collection system that they can keep and use at home if they are feeling sick. The home test detects 4 different kinds of flu and cold viruses, and all samples will be analyzed at a central laboratory that checks for 20 different viral infections. GoViral participants will get the results of their own tests and as well, through the aggregate data, be able to see in real-time what infections and symptoms are going around near them so they can take appropriate public health measures and understand when something might be abnormal.
Flu Near You is completely free to use. Results from the tests will be used for research purposes only. Data from each group will be aggregated and visualized in an easy to interpret yet anonymized manner.
How you will benefit: GoViral Participants will be able to track their own history throughout the season and learn what virus they have when they are feeling sick. As well, through the aggregate data, be able to see in real-time what infections and symptoms are going around right near them so they can take appropriate public health measures and understand when something might be abnormal.
Be involved in and shape an innovative model for the future of public health. Read details and join here. Contact the study lead, Dr. Rumi Chunara, at Goviral@flunearyou.org if you have questions.
Sunday, January 5, 2014
- 6:33 AM
- Unknown
- No comments
I'd like to make a number of subtle and not-so-subtle points today, and I hope you'll stick with me.
A friend and I have ongoing debates about whether Obamacare will make a difference in the practice of medicine in the US and whether that difference will be, for the most part, good or bad. Interestingly enough, we often find ourselves taking the opposite viewpoints from what we each argued a month or two earlier! Here's where I have come out after a nice winter break and having now viewed many health care institutions and societal arrangements around the world.
You cannot bolt on a communitarian solution to a health care system that is inherently impersonal and inhumane and expect that the resulting framework will have humanitarian characteristics. That, for all the commentary, is what Obamacare is trying to do and what its advocates proclaim is the future. They argue that changes in payment methodologies, an emphasis on preventative care and so-called "wellness,"* and integrated health care delivery systems will inexorably move us down the path to the Triple Aim: Improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
I would like to think that these folks (many of whom are close friends and distinguished experts) are right, but I think they are fundamentally wrong in their expectation that any externally imposed institutional framework will achieve those results. Please recognize that I am not in any way arguing against the tenets of Obamacare--universal access to health insurance and removal of nasty rules about pre-existing conditions and lifetime coverage limits. Nor am I making this argument because the President misrepresented the potential of the law when he promised access, choice, and lower costs. Indeed, I accept (reluctantly) that his set of promises was a necessary political precondition for getting anything through Congress and changing the shameful situation of millions of uninsured Americans.
Rather the issue is this: As we see from examples around the world, even where there is universal access to health care and where there is coordination across the spectrum of care from birth to hospice, the actual delivery of care as felt and seen by patients and families is simply substandard. By substandard, I mean that it seldom meets what I would call the gold standard: "The kind of care you would want for members of your own family." What does that standard imply? It implies a partnership between caregivers and patients and families of the sort so eloquently outlined by e-Patient Dave deBronkart and his medical partner-in-arms, Danny Sands and by Ted Eytan, Jim Conway, and Pat Sodomka. It implies a change in the way work is carried out in hospitals and other health care facilities, one that is respectful of front-line staff and empowers and encourages them to identify process improvement opportunities. It implies a full integration of human factors measures designed to offset the physical and neurological cognitive errors that human beings make, as MedStar's Terry Fairbanks has persuasively described. It implies a full integration of the principles of crew resource management into the hierarchical environment that has to exist in procedural settings, as practiced by Marck Haerkens and others. It implies an expanded view of health care system responsibilities in the community, of the sort practiced by Jeff Thompson and his engaged staff at Gundersen Lutheran.**
As you look at that list, you see that such changes are seldom if ever brought about by government fiat, whether legislative or regulatory. Likewise, they are virtually never the result of pricing designs or other actions by private or public payers. Neither are they dependent on such government rules or payer actions. Instead, they rise from within when the leadership of health care organizations--i.e., senior administrative and clinical leaders, supported by their governing bodies--have the desire, guts, and commitment to make them happen.
I've decided that it is distracting to expect the kind of global changes envisioned by the Obamacare advocates.*** The nature of change is that there will be industry leaders and industry laggards. In other fields, the "disruptive" organizations eventually overcome the incumbents and drive industry-wide structural change. In health care, this is less likely because of the geographical constraints on care delivery. While technology might mitigate some of those geographic factors, much of care will always require physical accessibility between patients and caregivers.
In light of this dispersed industry structure, I view my personal advocacy role as one quite different from many of my friends and colleagues. You see it in the masthead of this blog: I am an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement. I do not believe in global change, though, nor do I expect it to arrive or even be helped much by government leaders in Washington, London, Amsterdam, or Jerusalem. I aim not to change the world but to try to help organizations and leaders who are committed to this general direction and are willing to take the personal and professional risk that it is, quite simply, just the right thing to do. Those brave people, paradoxically, are usually the ones who, like Contra Costa's Anna Roth, are most modest about what they know, about how to accomplish change, and about progress to date.
With luck, publicity about our successes might help create a broader movement in support of the gold standard, but I am not counting on that. Meanwhile, we'll do our best to make life (and death) better for the patients and families and clinicians in those health systems that care and act like they care. That will be reward enough.
--
* Stay tuned on this front to a forthcoming book by Al Lewis and Vik Khanna.
** Beneath and around all those elements, the gold standard requires a different kind of training and reward system for physicians and other clinicians. By this, I do not mean a financial reward system. Such has been shown to be ineffective in so many settings. No, we need a reward system that is meaningful to those well-intentioned people who have devoted their lives to eliminating human suffering caused by disease. I'll return to that in future blog posts.
*** Take it further. As a thought experiment, or Gedankenexperiment, just consider what would have happened if we had simply expanded Medicare to the entire population. As we have seen, even this well-intentioned single payer system has never been able to escape from politically inspired rules and payment regimes that have done little to help us meet the Triple Aim, much less the gold standard outlined above.
A friend and I have ongoing debates about whether Obamacare will make a difference in the practice of medicine in the US and whether that difference will be, for the most part, good or bad. Interestingly enough, we often find ourselves taking the opposite viewpoints from what we each argued a month or two earlier! Here's where I have come out after a nice winter break and having now viewed many health care institutions and societal arrangements around the world.
You cannot bolt on a communitarian solution to a health care system that is inherently impersonal and inhumane and expect that the resulting framework will have humanitarian characteristics. That, for all the commentary, is what Obamacare is trying to do and what its advocates proclaim is the future. They argue that changes in payment methodologies, an emphasis on preventative care and so-called "wellness,"* and integrated health care delivery systems will inexorably move us down the path to the Triple Aim: Improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
I would like to think that these folks (many of whom are close friends and distinguished experts) are right, but I think they are fundamentally wrong in their expectation that any externally imposed institutional framework will achieve those results. Please recognize that I am not in any way arguing against the tenets of Obamacare--universal access to health insurance and removal of nasty rules about pre-existing conditions and lifetime coverage limits. Nor am I making this argument because the President misrepresented the potential of the law when he promised access, choice, and lower costs. Indeed, I accept (reluctantly) that his set of promises was a necessary political precondition for getting anything through Congress and changing the shameful situation of millions of uninsured Americans.
Rather the issue is this: As we see from examples around the world, even where there is universal access to health care and where there is coordination across the spectrum of care from birth to hospice, the actual delivery of care as felt and seen by patients and families is simply substandard. By substandard, I mean that it seldom meets what I would call the gold standard: "The kind of care you would want for members of your own family." What does that standard imply? It implies a partnership between caregivers and patients and families of the sort so eloquently outlined by e-Patient Dave deBronkart and his medical partner-in-arms, Danny Sands and by Ted Eytan, Jim Conway, and Pat Sodomka. It implies a change in the way work is carried out in hospitals and other health care facilities, one that is respectful of front-line staff and empowers and encourages them to identify process improvement opportunities. It implies a full integration of human factors measures designed to offset the physical and neurological cognitive errors that human beings make, as MedStar's Terry Fairbanks has persuasively described. It implies a full integration of the principles of crew resource management into the hierarchical environment that has to exist in procedural settings, as practiced by Marck Haerkens and others. It implies an expanded view of health care system responsibilities in the community, of the sort practiced by Jeff Thompson and his engaged staff at Gundersen Lutheran.**
As you look at that list, you see that such changes are seldom if ever brought about by government fiat, whether legislative or regulatory. Likewise, they are virtually never the result of pricing designs or other actions by private or public payers. Neither are they dependent on such government rules or payer actions. Instead, they rise from within when the leadership of health care organizations--i.e., senior administrative and clinical leaders, supported by their governing bodies--have the desire, guts, and commitment to make them happen.
I've decided that it is distracting to expect the kind of global changes envisioned by the Obamacare advocates.*** The nature of change is that there will be industry leaders and industry laggards. In other fields, the "disruptive" organizations eventually overcome the incumbents and drive industry-wide structural change. In health care, this is less likely because of the geographical constraints on care delivery. While technology might mitigate some of those geographic factors, much of care will always require physical accessibility between patients and caregivers.
In light of this dispersed industry structure, I view my personal advocacy role as one quite different from many of my friends and colleagues. You see it in the masthead of this blog: I am an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement. I do not believe in global change, though, nor do I expect it to arrive or even be helped much by government leaders in Washington, London, Amsterdam, or Jerusalem. I aim not to change the world but to try to help organizations and leaders who are committed to this general direction and are willing to take the personal and professional risk that it is, quite simply, just the right thing to do. Those brave people, paradoxically, are usually the ones who, like Contra Costa's Anna Roth, are most modest about what they know, about how to accomplish change, and about progress to date.
With luck, publicity about our successes might help create a broader movement in support of the gold standard, but I am not counting on that. Meanwhile, we'll do our best to make life (and death) better for the patients and families and clinicians in those health systems that care and act like they care. That will be reward enough.
--
* Stay tuned on this front to a forthcoming book by Al Lewis and Vik Khanna.
** Beneath and around all those elements, the gold standard requires a different kind of training and reward system for physicians and other clinicians. By this, I do not mean a financial reward system. Such has been shown to be ineffective in so many settings. No, we need a reward system that is meaningful to those well-intentioned people who have devoted their lives to eliminating human suffering caused by disease. I'll return to that in future blog posts.
*** Take it further. As a thought experiment, or Gedankenexperiment, just consider what would have happened if we had simply expanded Medicare to the entire population. As we have seen, even this well-intentioned single payer system has never been able to escape from politically inspired rules and payment regimes that have done little to help us meet the Triple Aim, much less the gold standard outlined above.
Friday, January 3, 2014
- 8:23 AM
- Unknown
- No comments
My old dog (age 12+) acts like she is 2 when there’s snow like this – makes me hope that my last walk with her on the day I will need to put her down is on a snowy winter day when we can walk in the snow for a last time.
This 10-year-old pooch from the East Coast demonstrates the joy!
Thursday, January 2, 2014
- 9:56 PM
- Unknown
- No comments
"Hello this is Pacific Gas & Electric calling. We would like to let you know that your area may currently be experiencing a power outage, and we apologize for any inconvenience this may cause. We are deploying Cruise to investigate the cause of the outage and make repairs. Based on historical data for outages in this location, we expect to restore power or provide an updated estimate by eleven thirty am. . . ."
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