There's an old bar con about going up to someone asking for a loan of $10. "But," you say, "only give me $5. That way, you keep $5, and we'll be even." Sometimes people fall for it.
Fair or not, that's what some new research about the value of the tax exemption for non-profit hospitals made me think of.
The study, in Health Affairs, by Rosenbaum, et. alia, found that the value of the exemption virtually doubled between 2002 and 2011, increasing from $12.6b to $24.6b. The tax breaks -- which typically apply at the federal, state, and local levels -- are supposed to be in return for "charity care and community benefit."
According to IRS filings submitted by hospitals for 2011, the researchers calculated that the charitable and community benefits claimed were $62.4b. The AHA was quick to jump on the findings: "Today's report shows that what non-profit hospitals provide in terms of benefit to their communities far exceeds the value of the tax exemption hospitals receive," it said in a statement, "...hospitals of every size, type and general location are not only meeting, but are exceeding, the community benefit obligations conferred by their tax-exempt status."
Not so fast.
It turns out that most of the money is spent, in essence, "paying" themselves back, such as for indigent care (24%) or to cover Medicaid shortfalls (32%). As lead author Sara Rosenbaum told MedPage News, "These are very good things, but very little is going to community health improvement." Indeed, only about 8% actually went back to the community.
It's not entirely clear how hospitals are even calculating these benefits. AHA insists they are based on actual costs, not charges, but the last time hospitals knew their actual costs was, well, never. Certainly the IRS isn't auditing the filings, leading some critics to believe that hospitals use their wildly inflated charges to boost their apparent community benefit.
It's sort of, OK, I'm going to charge you $10 for an aspirin, but you just pay me $2 and I'll write off $8 in community benefit. Call me cynical, but any organization that thinks it is good business to gouge uninsured patients is not an organization that I have much faith in how they're justifying their tax exemption.
ACA requires non-profit hospitals to conduct a community health needs assessment, or CHNA, every three years in order to maintain their tax exemption. Ms. Rosenbaum hopes that the CHNA will lead to a new era of transparency and accountability. She thinks hospitals could spend their community benefits in underserved areas in creative ways, such as cleaning up parks or helping to make fresh produce more available. "It may have nothing to do with clinical care,” Ms. Rosenbaum pointed out. “These are things that improve community health."
ACA has been seen as a boon for hospitals, increasing the number of insured and decreasing uncompensated care (just look at what happened to for-profit hospitals' stocks following last week's SCOTUS decision on maintaining subsidies). Ms. Rosenbaum told Dotmed News, "As hospitals have essentially realized a dividend from the Affordable
Care Act, the question is, will city members be at the table more than
they were before?"
I wouldn't hold my breath.
The tax-exempt/non-profit status for health organizations is under more scrutiny than ever. A court ruling in New Jersey found that Morristown Medical Center so intermingled its for-profit and non-profit activities that it no longer qualified for a state tax exemption, potentially making it -- and other NJ hospitals -- liable for millions of dollars in property taxes.
There is still an appeals process for MMC, and the NJ legislature may act to address the issue, but other states are also taking a harder look at their tax exemptions for non-profit health care organizations. California is already trying to take away the non-profit status of Blue Shield, and is now taking a harder look at its non-profit hospitals. Cash-strapped Kansas is looking at making non-profit hospitals pay sales tax, while North Carolina is considering ending its sales tax refund program to non-profit hospitals. Advocates in Oregon are questioning the community benefits their non-profit hospitals are delivering.
Maybe some of these questions are arising because salaries for non-profit hospital leaders are looking a lot like for-profit salaries. Last year Modern Healthcare found that non-profit hospital CEO compensation rose, on average, 24% from 2011 to 2012 for the 147 institutions it tracks, while compensation for average workers only rose 2%. The average CEO cash compensation was $2.2 million.
UPMC's long-time CEO Jeff Romoff reportedly made $6.5 million in 2014, one of 30 -- count 'em, 30! -- UPMC executives making over $1 million. Connecticut's Office of Health Care Access found 19 health care executives in the state making over $1 million. The Columbus Business First found at least 11 Ohio hospital CEOs making over $1 million.
I could go on, but I think the point is made. I'm not saying these hospital executives don't earn their money, I'm just saying that, at some point, non-profits start to look and act an awfully lot like for-profits...without having to pay taxes or be accountable to shareholders.
There are, no doubt, a number of non-profit hospitals struggling to survive, especially those in rural or inner city areas. Suburban hospitals with significant privately insured patient populations are usually the ones going on the building binges and aggressively increasing their horizontal and vertical market reach, through a combination of non-profit and for-profit businesses. Those are the ones whose non-profit status and community benefits especially deserve closer scrutiny.
Ms. Rosenbaum concluded, "Hospitals view themselves as caring for sick people, but the pressure is
growing for them to improve the health of an entire population .... To
the extent that it's burdensome, this underscores the major public
investment that is the tax exemption."
That's a new way for them to act and a new way for us to think about our investment in them, but both need to happen.
It's not just hospitals. Many of the above criticisms apply to other non-profit health care organizations as well. E.g., many Blue plans remain nominally non-profit and thus reap a variety of tax exemptions and/or preferences. They sometimes justified that at least in part by offering some guaranteed issue products, which are, of course, now required of all health plans. So why isn't their associated community benefit/tax exemption less?
Every tax dollar that hospitals and other health organizations don't pay is a tax dollar that someone else -- that's you and me, in case you were wondering -- is paying. Let's make sure they truly deserve their tax exemptions and that those community benefits are actually going back to the community, not just staying within their walls.
Monday, June 29, 2015
Thursday, June 18, 2015
Jurassic Park: Rise of the Health Insurers
If you want to see dinosaurs fighting, stalking, and even mating, you don't need to go see Jurassic World. Just pick up the business pages and see what is going on with the big health insurers, who seem intent on getting even bigger.
Whether anything actually comes of all the merger mania, or whether such mergers prove good for consumers, remains to be seen.
A month ago Humana seemed the most likely target, with Aetna the most likely suitor. Humana was not too big, not too small, and their big book of Medicare Advantage business complimented Aetna's more commercial portfolio. Cigna was mentioned as another possible target, but pretty much only offered Aetna more of what they already had.
Shortly after that rumor started, Anthem got tongues wagging by their CFO telling analysts they were looking "to do a cash transaction of meaningful size." The speculation again centered on Humana, or possibly some Medicaid insurers like Molina or Centene.
Now, everyone seems to be in play. The Wall Street Journal reported that Anthem has made overtures to Cigna, while United is interested in Aetna, with Humana still attractive to Aetna and Cigna. Here's the WSJ infographic:
You can't make this stuff up.
It would be ironic if Humana was one left standing in this game of musical chairs, but many feel their assets are too inviting to be left out.
The Anthem/Cigna combination struck me as the oddest. Anthem is historically and primarily a Blue Cross Blue Shield plan. BCBSA rules are pretty strict about not combining Blue and non-Blue business, which could limit taking advantage of the consolidation to get more clout in negotiating with providers. Then I remembered that Anthem already has a substantial non-branded line of business through its UniCare subsidary, whose self-funded, large employer portfolio would mesh very well with Cigna's strong presence in the large employer market.
The United/Aetna combination, on the other hand, might pose concerns with regulators, although in most markets might still pass FTC market share tests. United is less likely to be interested in Humana because it already has a strong Medicare presence, between its Medicare Advantage business and its AARP health insurance products.
I'll let others talk about market caps, stock prices, P/E rations and the like. I'm more interested in why we're seeing this, and what we're not seeing.
One conventional wisdom is that these kinds of mergers/acquisitions have to do with scale, since ACA puts restrictions on health plans' overhead (the MLR). Bigger means more lives to spread such costs over. The other culprit often cited is a desire to gain more clout with providers, who themselves are consolidating, although mostly at the local rather than the national/regional level.
I've expressed my concerns about provider consolidation before. Health systems seem intent to gain control of geographic areas, which can be as large as whole metropolitan areas. They usually do so in the name of fending off bigger and bigger health plans, or say it is part of a strategy to be an integrated delivery system, which is becoming more important in an ACO/value-based world.
The trouble is, no matter how big health plans get, if they face markets where there is, in essence, only one provider with which to negotiate, size doesn't really matter. If a health plan can't convince their members to drive much longer to go to another health system, it doesn't matter if they have ten members or a million members when it comes to playing tough with the dominant health system. Bigger isn't always better.
You can make dinosaurs bigger, but that doesn't make them more agile or better prepared to deal with new risks. I'm wondering when we're going to see not bigger health insurers, but truly different models for them.
It wasn't all that long ago that pundits were predicting the end of health insurers. They were going to be replaced by ACOs and other delivery systems bearing risk. ACOs are certainly booming, but the stock market doesn't seem too worried about health insurers going out of business.
We've seen true integrated provider/health plan models like Kaiser, Group Health Cooperative, or Geisinger for decades now, and they're generally successful in their core markets, but that model hasn't proved easily replicable.
We've also seem health system building their own health plans, such as Intermountain Healthcare, Sentara, or UPMC. We've even seen health plans buying/building their own health systems, such as UPMC's bitter rival Highmark Health. Two years ago Anthem chose the leader of a large hospital system as its new CEO, signaling that the lines were going to be blurrier.
It's again kind of ironic to remember that Humana started out as a nursing home company, became a hospital chain, got into the health insurance business, and only shed its provider side in the early 1990s.
If Anthem buys Cigna or United buys Aetna, it wouldn't be all that interesting, nor would it be novel. Those are dinosaurs getting bigger but not evolving. We've already seen those kinds of combinations. They might be good for investors but raise your hand if you think they've ever really led to breakthroughs in health for their patients/members.
If, on the other hand, Humana and HCA got back together, that would be interesting. That would be provider/payor integration writ large, and maybe produce something new.
And if, say, CVS or Walgreens chose to merge with a health insurer, that would something even more unique. I don't know how they'd change the health insurer, but it might be fun to find out.
Honestly, though, what I'd really love to see is a company from an entirely different sector, hopefully one with a strong consumer focus, buy into the health insurance business. Maybe Humana should get back together with the Virgin Group, or perhaps Walmart would be interested in taking over a Medicaid managed care or Medicare Advantage plan. Wouldn't you love to see Walmart take on the health care supply chain? I bet they could squeeze better value out for its customers.
Jurassic World seems to be raking in the money despite being just another sequel about rogue dinosaurs. Let's hope we see something with health insurers that isn't just another sequel as well.
Whether anything actually comes of all the merger mania, or whether such mergers prove good for consumers, remains to be seen.
A month ago Humana seemed the most likely target, with Aetna the most likely suitor. Humana was not too big, not too small, and their big book of Medicare Advantage business complimented Aetna's more commercial portfolio. Cigna was mentioned as another possible target, but pretty much only offered Aetna more of what they already had.
Shortly after that rumor started, Anthem got tongues wagging by their CFO telling analysts they were looking "to do a cash transaction of meaningful size." The speculation again centered on Humana, or possibly some Medicaid insurers like Molina or Centene.
Now, everyone seems to be in play. The Wall Street Journal reported that Anthem has made overtures to Cigna, while United is interested in Aetna, with Humana still attractive to Aetna and Cigna. Here's the WSJ infographic:
You can't make this stuff up.
It would be ironic if Humana was one left standing in this game of musical chairs, but many feel their assets are too inviting to be left out.
The Anthem/Cigna combination struck me as the oddest. Anthem is historically and primarily a Blue Cross Blue Shield plan. BCBSA rules are pretty strict about not combining Blue and non-Blue business, which could limit taking advantage of the consolidation to get more clout in negotiating with providers. Then I remembered that Anthem already has a substantial non-branded line of business through its UniCare subsidary, whose self-funded, large employer portfolio would mesh very well with Cigna's strong presence in the large employer market.
The United/Aetna combination, on the other hand, might pose concerns with regulators, although in most markets might still pass FTC market share tests. United is less likely to be interested in Humana because it already has a strong Medicare presence, between its Medicare Advantage business and its AARP health insurance products.
I'll let others talk about market caps, stock prices, P/E rations and the like. I'm more interested in why we're seeing this, and what we're not seeing.
One conventional wisdom is that these kinds of mergers/acquisitions have to do with scale, since ACA puts restrictions on health plans' overhead (the MLR). Bigger means more lives to spread such costs over. The other culprit often cited is a desire to gain more clout with providers, who themselves are consolidating, although mostly at the local rather than the national/regional level.
I've expressed my concerns about provider consolidation before. Health systems seem intent to gain control of geographic areas, which can be as large as whole metropolitan areas. They usually do so in the name of fending off bigger and bigger health plans, or say it is part of a strategy to be an integrated delivery system, which is becoming more important in an ACO/value-based world.
The trouble is, no matter how big health plans get, if they face markets where there is, in essence, only one provider with which to negotiate, size doesn't really matter. If a health plan can't convince their members to drive much longer to go to another health system, it doesn't matter if they have ten members or a million members when it comes to playing tough with the dominant health system. Bigger isn't always better.
You can make dinosaurs bigger, but that doesn't make them more agile or better prepared to deal with new risks. I'm wondering when we're going to see not bigger health insurers, but truly different models for them.
It wasn't all that long ago that pundits were predicting the end of health insurers. They were going to be replaced by ACOs and other delivery systems bearing risk. ACOs are certainly booming, but the stock market doesn't seem too worried about health insurers going out of business.
We've seen true integrated provider/health plan models like Kaiser, Group Health Cooperative, or Geisinger for decades now, and they're generally successful in their core markets, but that model hasn't proved easily replicable.
We've also seem health system building their own health plans, such as Intermountain Healthcare, Sentara, or UPMC. We've even seen health plans buying/building their own health systems, such as UPMC's bitter rival Highmark Health. Two years ago Anthem chose the leader of a large hospital system as its new CEO, signaling that the lines were going to be blurrier.
It's again kind of ironic to remember that Humana started out as a nursing home company, became a hospital chain, got into the health insurance business, and only shed its provider side in the early 1990s.
If Anthem buys Cigna or United buys Aetna, it wouldn't be all that interesting, nor would it be novel. Those are dinosaurs getting bigger but not evolving. We've already seen those kinds of combinations. They might be good for investors but raise your hand if you think they've ever really led to breakthroughs in health for their patients/members.
If, on the other hand, Humana and HCA got back together, that would be interesting. That would be provider/payor integration writ large, and maybe produce something new.
And if, say, CVS or Walgreens chose to merge with a health insurer, that would something even more unique. I don't know how they'd change the health insurer, but it might be fun to find out.
Honestly, though, what I'd really love to see is a company from an entirely different sector, hopefully one with a strong consumer focus, buy into the health insurance business. Maybe Humana should get back together with the Virgin Group, or perhaps Walmart would be interested in taking over a Medicaid managed care or Medicare Advantage plan. Wouldn't you love to see Walmart take on the health care supply chain? I bet they could squeeze better value out for its customers.
Jurassic World seems to be raking in the money despite being just another sequel about rogue dinosaurs. Let's hope we see something with health insurers that isn't just another sequel as well.
Sunday, June 14, 2015
The Enemy of My Enemy Is Still My Enemy
The old adage says that the enemy of my enemy is my friend. Several lawsuits within new health care spaces -- telemedicine, wearables, and concierge medicine -- would seem to belie this conventional wisdom.
The first example is with American Well and Teladoc, two of the nation's oldest and largest telemedicine companies. American Well is suing Teladoc for what it says are patent infringements. It doesn't seem like it is a coincidence that Teladoc recently announced that they were getting ready to go public, or that in March Teladoc sought to get the U.S. Patent Office to invalidate the patents in question, which date back to 2007.
Both companies seem to be doing well. American Well raised $81 million last December, while Teladoc secured another $50 million last September. According to MobiHealth News' analysis of their IPO filing, Teladoc has close to 11 million members, and is on track for over 600,000 visits annually in 2015. American Well claims to have over 23 million members, mostly through its various health plan and provider clients.
They're certainly not alone in the field -- MDLive and Doctors on Demand also seem to be doing well, as evidenced by MDLive's burgeoning deal with Walgreens and Doctors on Demand's new deal with Wegmans-- but they are the largest. And now they're squabbling with each other in court.
They've got plenty of other battles that they should be focusing on. Texas is ground zero, with the recent ruling by the Texas Medical Board to require in-person visits in order to write prescriptions, which is viewed as a major barrier for telemedicine (Texas is not the only state with such restrictions). Teladoc sued the TMB, and recently got a ruling from a Federal District Court blocking the TMB ruling.
This is important stuff for telemedicine. Much progress has been made on making telemedicine more mainstream, but there is still a long way to go. For example, the AMA's ethics council appeared to be close to making some progress on their official attitude towards telemedicine, only to punt after pressure from the TMB (I'm guessing they figured that the AMA getting ahead of the TMB would weaken their court case).
Similarly, just this week the American Telemedicine Association criticized the CMS final rules on telemedicine in ACOs, organizational models that should be front and center in using it.
I don't know what American Well patents Teladoc may have infringed on, or if they did whether they had any right to do so, and I don't support industrial espionage in lieu of real competition, but telemedicine is not yet so well established that its leaders should be attacking each other instead of trying to further its reach.
Also under the cause of patent infringement, Jawbone is suing Fitbit. It is actually Jawbone's second lawsuit against them in two weeks. Not only is Jawbone claiming patent infringement, they are planning to take their complaint to the International Trade Commission, which could result in a ban on imports of Fitbit products or components. Their earlier lawsuit related to loss of intellectual property caused by Fitbit hiring several Jawbone employees.
It, again, comes as probably not a coincidence that Fitbit is preparing for its IPO on June 17.
Analysts are predicting crazy growth rates for wearables, such as one prediction that the global market could be worth $37b by 2020, and estimates of 2015 sales ranging from IDC's 45.7 million units to Yanos Research Institute's forecast of 104.8. The market would seem to have room for both companies.
I wish Jawbone and Fitbit were spending more time figuring out what they are going to do about competing with new entrants in the wearable space like Apple or Samsung, and how they can do a better job keeping consumers from giving up on them. They are not each other's biggest problem.
These internecion legal wars are not limited to patent disputes. The two leaders in concierge medicine -- MDVIP and Signature MD -- are in court over non-compete provisions.
To be more accurate, Signature MD is suing the much larger MDVIP. MDVIP's contracts with physicians prohibit them from joining another concierge practice within ten miles of a MDVIP practice for up to two years after their contract ends. SignatureMD says these provisions are unenforceable, and a federal court in Los Angeles has already dismissed MDVIP's effort to squash the suit.
SignatureMD claims that MDVIP has something like 70% market share, and that its contracts effectively lock up many major markets. MDVIP points out that SignatureMD's market share estimates include only physicians practicing the model, which remains only a small fraction of available physicians.
Concierge medicine, and its related model of direct primary care, are darlings of reformers who feel that health insurance is distorting how health care is bought and delivered. A 2014 survey by Merritt Hawkins found that 7% of physicians already practice some form of these models, with another 13% planning to. To SignatureMD's point, there are a lot of untapped physicians out there.
I don't like non-compete provisions, but I understand that companies like to protect their investments. There are reasonable limits and unreasonable limits, and courts will end up figuring out where the line is, but in the meantime their fighting in court is not doing much to move the cause of concierge medicine forward.
I worry more about health systems locking up physicians in their markets (e.g., see what is happening in Washington and New Mexico) than I do about 10-20% of physicians in a market being tied to a particular concierge medicine company. I'd rather those companies seek to expand the number and range of physicians using a concierge approach in their practice.
Patent infringement and non-compete provisions are neither trivial nor unique to these health care spaces, and I don't mean to imply that they are. All the companies I've mentioned are innovators who deserve to be commended for helping to break traditional health care paradigms. They've won impressive battles to gain more acceptance for their approaches. But the wars haven't been won yet, and with these various legal battles it feels like they are taking their eyes off the prize.
If they're going to go to court, I'd rather that they focused on the people and organizations who still seek to limit adoption of their services, not each other.
The first example is with American Well and Teladoc, two of the nation's oldest and largest telemedicine companies. American Well is suing Teladoc for what it says are patent infringements. It doesn't seem like it is a coincidence that Teladoc recently announced that they were getting ready to go public, or that in March Teladoc sought to get the U.S. Patent Office to invalidate the patents in question, which date back to 2007.
Both companies seem to be doing well. American Well raised $81 million last December, while Teladoc secured another $50 million last September. According to MobiHealth News' analysis of their IPO filing, Teladoc has close to 11 million members, and is on track for over 600,000 visits annually in 2015. American Well claims to have over 23 million members, mostly through its various health plan and provider clients.
They're certainly not alone in the field -- MDLive and Doctors on Demand also seem to be doing well, as evidenced by MDLive's burgeoning deal with Walgreens and Doctors on Demand's new deal with Wegmans-- but they are the largest. And now they're squabbling with each other in court.
They've got plenty of other battles that they should be focusing on. Texas is ground zero, with the recent ruling by the Texas Medical Board to require in-person visits in order to write prescriptions, which is viewed as a major barrier for telemedicine (Texas is not the only state with such restrictions). Teladoc sued the TMB, and recently got a ruling from a Federal District Court blocking the TMB ruling.
This is important stuff for telemedicine. Much progress has been made on making telemedicine more mainstream, but there is still a long way to go. For example, the AMA's ethics council appeared to be close to making some progress on their official attitude towards telemedicine, only to punt after pressure from the TMB (I'm guessing they figured that the AMA getting ahead of the TMB would weaken their court case).
Similarly, just this week the American Telemedicine Association criticized the CMS final rules on telemedicine in ACOs, organizational models that should be front and center in using it.
I don't know what American Well patents Teladoc may have infringed on, or if they did whether they had any right to do so, and I don't support industrial espionage in lieu of real competition, but telemedicine is not yet so well established that its leaders should be attacking each other instead of trying to further its reach.
Also under the cause of patent infringement, Jawbone is suing Fitbit. It is actually Jawbone's second lawsuit against them in two weeks. Not only is Jawbone claiming patent infringement, they are planning to take their complaint to the International Trade Commission, which could result in a ban on imports of Fitbit products or components. Their earlier lawsuit related to loss of intellectual property caused by Fitbit hiring several Jawbone employees.
It, again, comes as probably not a coincidence that Fitbit is preparing for its IPO on June 17.
Analysts are predicting crazy growth rates for wearables, such as one prediction that the global market could be worth $37b by 2020, and estimates of 2015 sales ranging from IDC's 45.7 million units to Yanos Research Institute's forecast of 104.8. The market would seem to have room for both companies.
I wish Jawbone and Fitbit were spending more time figuring out what they are going to do about competing with new entrants in the wearable space like Apple or Samsung, and how they can do a better job keeping consumers from giving up on them. They are not each other's biggest problem.
These internecion legal wars are not limited to patent disputes. The two leaders in concierge medicine -- MDVIP and Signature MD -- are in court over non-compete provisions.
To be more accurate, Signature MD is suing the much larger MDVIP. MDVIP's contracts with physicians prohibit them from joining another concierge practice within ten miles of a MDVIP practice for up to two years after their contract ends. SignatureMD says these provisions are unenforceable, and a federal court in Los Angeles has already dismissed MDVIP's effort to squash the suit.
SignatureMD claims that MDVIP has something like 70% market share, and that its contracts effectively lock up many major markets. MDVIP points out that SignatureMD's market share estimates include only physicians practicing the model, which remains only a small fraction of available physicians.
Concierge medicine, and its related model of direct primary care, are darlings of reformers who feel that health insurance is distorting how health care is bought and delivered. A 2014 survey by Merritt Hawkins found that 7% of physicians already practice some form of these models, with another 13% planning to. To SignatureMD's point, there are a lot of untapped physicians out there.
I don't like non-compete provisions, but I understand that companies like to protect their investments. There are reasonable limits and unreasonable limits, and courts will end up figuring out where the line is, but in the meantime their fighting in court is not doing much to move the cause of concierge medicine forward.
I worry more about health systems locking up physicians in their markets (e.g., see what is happening in Washington and New Mexico) than I do about 10-20% of physicians in a market being tied to a particular concierge medicine company. I'd rather those companies seek to expand the number and range of physicians using a concierge approach in their practice.
Patent infringement and non-compete provisions are neither trivial nor unique to these health care spaces, and I don't mean to imply that they are. All the companies I've mentioned are innovators who deserve to be commended for helping to break traditional health care paradigms. They've won impressive battles to gain more acceptance for their approaches. But the wars haven't been won yet, and with these various legal battles it feels like they are taking their eyes off the prize.
If they're going to go to court, I'd rather that they focused on the people and organizations who still seek to limit adoption of their services, not each other.
Saturday, June 6, 2015
The Gift That Just Keeps On Giving
In my last post I wrote about some new woes for EHRs, such as malpractice risks, and I honestly didn't expect to write about them so soon. But an article in Politico caught my eye, describing a huge problem with them that may not be top of mind for many: the risk (and cost) of being hacked.
In short, the health care industry has spent/is spending billions installing EHRs, more billions getting them to work, and is now realizing that they're going to have to keep spending billions each year to try to protect the information in them, as well as in other digital devices.
Say what you will about paper records, but it was awfully hard to steal too many of them. The opaqueness that made them difficult to share/collaborate/analyze also made them virtually impossible to get remote access into. Unlike EHRs.
The Politico article says that an individual medical record is worth ten times as much as a stolen credit card, that each hacked record can cost around $20 in legal costs and credit protection, and that the growing market for cyberinsurance is already a $2b industry, growing at 20-25% annually.
A May 2015 report from The Ponemon Institute lays out some other scary findings:
Politico cites industry experts who recommend spending 10% of IT budgets on security, and up to 40% for newer companies, versus the industry average of 3%. No wonder that only 37% of the organizations in the Ponemon survey felt their budget was sufficient to curtail or minimize breaches.
Breaches have become almost numbingly common in health care. In recent months, there have been known breaches at Anthem, CareFirst, Kaiser, Premera, as well as a number of provider organizations, including Community Health Systems. Just a few days ago personnel records on up to 4 million current or retired federal employees were hacked, and many believe that Chinese hackers suspected of being behind the attacks were the same hackers who attacked the big insurers.
In short, the health care industry has spent/is spending billions installing EHRs, more billions getting them to work, and is now realizing that they're going to have to keep spending billions each year to try to protect the information in them, as well as in other digital devices.
Say what you will about paper records, but it was awfully hard to steal too many of them. The opaqueness that made them difficult to share/collaborate/analyze also made them virtually impossible to get remote access into. Unlike EHRs.
The Politico article says that an individual medical record is worth ten times as much as a stolen credit card, that each hacked record can cost around $20 in legal costs and credit protection, and that the growing market for cyberinsurance is already a $2b industry, growing at 20-25% annually.
A May 2015 report from The Ponemon Institute lays out some other scary findings:
- Criminal attacks are now the leading cause of health data breaches, up 125% over the last five years.
- 65% of health organizations suffered multiple security incidents over the past 2 years.
- Data breaches cost the industry $6b annually.
- Employee negligence is still easily the leading source of concern.
- Only about half of health care organizations think they have the right technologies or technical expertise to deter breaches, and slightly less than half are confident they can even detect loss or theft of patient data.
Politico cites industry experts who recommend spending 10% of IT budgets on security, and up to 40% for newer companies, versus the industry average of 3%. No wonder that only 37% of the organizations in the Ponemon survey felt their budget was sufficient to curtail or minimize breaches.
Breaches have become almost numbingly common in health care. In recent months, there have been known breaches at Anthem, CareFirst, Kaiser, Premera, as well as a number of provider organizations, including Community Health Systems. Just a few days ago personnel records on up to 4 million current or retired federal employees were hacked, and many believe that Chinese hackers suspected of being behind the attacks were the same hackers who attacked the big insurers.
As FBI Director James Comey told 60 Minutes earlier this year, "There are two kinds of big companies in the
United States. There are those who've been hacked by the Chinese and those who
don't know they've been hacked by the Chinese."
Just to be fair, it's not all about EHRs. TrapX, a cybersecurity company, told The New York Times that Russian and Chinese hackers are infiltrating through other medical devices, such as x-ray systems or blood gas analyzers. "This is going to get worse before it gets better, said TrapX's Carl Wright. No wonder; "Clinical software is riddled with security vulnerabilities," claims Billy Rios of Laconicly, another security firm.
And institutional clinical software looks pretty secure compare to all those mobile apps and wearable trackers.
There are a number of strategies that health care organizations can follow to combat cyberattacks, such as de-identification and encryption of data, as well as better monitoring of hacking attempts. For example, neither Anthem nor the U.S. government encrypted that data that was stolen. However, in at least the Anthem case, it wouldn't have mattered, since the hackers used employee credentials that got them past the firewalls (as was true with last year's Sony breach). Employees remain one of the biggest vulnerabilities.
Apple CEO Tim Cook has offered another perspective, that despite all of our concern about hackers stealing our information we're blithely giving it away anyway, He implicitly criticized competitors like Facebook and Google who offer "free services" that he believes are pretexts for their gobbling up our personal information so that they can better target market us.
As a boss of mine liked to always say, there's so such thing as a free lunch.
In a recent op-ed. Professor Zeynep Tufecki of UNC called on Mark Zuckerberg (and, by extension, other "free" services) to let her pay for her Facebook in return for less tracking and more privacy. I wonder on how many people would actually opt for such an approach.
Indeed, a new study by the Annenberg School of Communications found that the public is well aware that their online data is being used to market to them, but 91% don't think the trade-offs are "fair." Annenberg thinks the public is just resigned to the practice, feeling powerless to do anything about it. Two recent polls by the Pew Research Center confirm that over 90% of Americans think it is important to control who collects what information about them, but are skeptical that their information -- especially online information -- will remain private and secure.
Look, we're not going back to a pre-digital world. And in the digital world, there will be people who want to get access to our information, either legally or illegally. Health organizations like to think they are in the patient business, but in the 21st century that means they are in the data business, which puts them squarely in the privacy business. That means they need to invest sufficiently in IT resources and security.
Health care now requires patient care, data analytics, and data custodianship, but there's no reason why any single organization needs to perform each of those itself. Being a health care data custodian for health organizations might become a very hot business (as I've suggested before).
Privacy doesn't mean what it used to mean, with more people increasingly opting for convenience over traditional notions of it, and with more ways to subvert it. We're going to have to figure out what is most important to us and how best to protect it.
Wednesday, May 27, 2015
First, We Sue All the EHRs
There appears to be a new tactic in medical malpractice suits: blame the EHR. Oh, great; something else we can try to make their fault.
Evidence for this trend is, at this point, more directional than statistically significant. An analysis by The Doctors Company, a large medical malpractice insurer, found that EHRs were a contributing factor in less than 1% of suits from 2007 - 1H 2014, but that the rate had doubled in the last few months of the study.
Experts suggest that the percentages are still small because EHR adoption did not really pick up until after HITECH passed in 2009, and that malpractice cases usually take several years to work themselves through the legal system. So what we're seeing now may be the tip of the iceberg.
Other research is mixed. A 2015 review of the literature by RTI International for HHS on health IT's impact on patient safety concluded that it most definitely can help, including lowering the risk for malpractice claims. A study by CRICO, another malpractice insurer, found that EHRs offer new types of risks -- some user error, some system-based. Half of the cases they found resulted in "severe injury." Incorrect information accounted for 20% of errors, although a variety of system failures were responsible for even more.
Fair enough to say that if EHRs work as intended, and if they are are used properly, then they can help reduce risks and improve patient outcomes...but both those "ifs" are not certainties by any means. Thus the risk for malpractice and other legal risks.
The issue became visible last fall during the U.S Ebola scare, when the hospital with patient zero initially blamed its EHR for missing key information that would have helped them spot the proper diagnosis earlier, only to be firmly rebutted by Epic, the EHR vendor. The facts appear to be that the problem was not the EHR itself but the workflow and how information in the EHR got viewed by whom (e.g., nurses notes were not readily visible to doctors).
I'll bet Epic felt it dodged a bullet, but they shouldn't be too complacent. EHR vendors represent deeper pockets than most providers, which makes them a tempting target for lawsuits. As Computerworld put it in an article last month, Lawyers smell blood in electronic medical records.
The article cited Keith Klein, a professor of medicine at UCLA, as describing four cases where the judgments were over $7.5 million because the data in the EHR couldn't be trusted. Dr. Klein told Computerworld: "There are attorneys now looking for a clean case to sue the vendor. This is reality. It is not theoretical."
Deep pockets, here we come.
In a related post, Dr. Jeffrey Guterman, another professor at UCLA, criticizes the push for meaningful use, suggesting that "meaningful users" are more important. Dr. Guterman believes that once HITECH passed, EHR vendors made a land grab for market share, with the unintended consequence of diverting resources devoted to R&D and technology advancement.
Dr. Guterman further says that most EHR systems were built from billing platforms and/or use database structures that are well over thirty years old. These lead directly to the interoperability issues that I've written about before, and which helps explain the EHR vendors' thirst for market share: once they get a customer, they know how difficult it will be for them to ever leave.
"Information blocking" is the new term being used for this intentional desire to confine patient information to a specific EHR platform. ONC recently released a requested report on the topic to Congress, acknowledging that the practice is happening. ONC also detailed the actions that it is already taking, or proposing to take, to address the practice, while noting that "many types of information blocking are beyond the reach of current federal law and programs to address."
A Health Affairs blog post by Julia Adler-Milstein notes both that "ONC makes plain that this behavior will no longer be tolerated," and that the criteria used to define what constitutes information blocking will be very difficult to prove, as the conduct has to be "objectively unreasonable in light of public policy." As she says, "There is no question that the CEO of a large electronic health record vendor would have quite a different definition of “reasonable” than would our National Coordinator for Health IT." Or a hospital CEO.
While ONC, many providers, and even some EHR vendors see a problem, Epic continues to deny there is one. An Epic vice-president told The New York Times, "We do not participate in any activities that could be described as information blocking. To our knowledge, these activities are very rare, if they exist at all."
I'll bet he even said it with a straight face.
Congress inadvertently created the problem, and it can (in theory) pass all the laws ONC suggests to address it, but the truth is that information blocking is likely to continue until information sharing is a financial advantage to providers. That may end up being true within an ACO (although many health systems are trying to accomplish this by making affiliated providers get on their EHR platform), but otherwise there is not much incentive to share.
As Dr. Adler-Milstein concluded, "When the C-suite truly believes that they can be most successful by competing on the basis of sharing and using data, rather than hoarding and controlling data, we will know that we have succeeded." It's just hard to think of too many industries where companies compete by sharing their data.
I keep thinking of a recent Fortune article by Kentaro Toyama, Professor Toyama throws cold water on the hope that technology will help control health costs. His "Law of Amplification" asserts that:
Many readers probably recognized that my title referenced Shakespeare's "The first thing we do, let's kill all the lawyers" from Henry VI. I have to admit that, until I looked it up, I assumed it was referring to venial or corrupt lawyers. In fact, it means the opposite: it was spoken by a character trying to overthrow the government and the rule of law.
So it is with EHRs. We shouldn't get caught up in blaming them for their perceived shortcomings and hamstringing their development with more rules. Instead, we should do a better job of creating the appropriate environment for them to rapidly evolve to help improve care.
For previous thoughts on how to do that, try here, here, here, and here.
Evidence for this trend is, at this point, more directional than statistically significant. An analysis by The Doctors Company, a large medical malpractice insurer, found that EHRs were a contributing factor in less than 1% of suits from 2007 - 1H 2014, but that the rate had doubled in the last few months of the study.
Experts suggest that the percentages are still small because EHR adoption did not really pick up until after HITECH passed in 2009, and that malpractice cases usually take several years to work themselves through the legal system. So what we're seeing now may be the tip of the iceberg.
Other research is mixed. A 2015 review of the literature by RTI International for HHS on health IT's impact on patient safety concluded that it most definitely can help, including lowering the risk for malpractice claims. A study by CRICO, another malpractice insurer, found that EHRs offer new types of risks -- some user error, some system-based. Half of the cases they found resulted in "severe injury." Incorrect information accounted for 20% of errors, although a variety of system failures were responsible for even more.
Fair enough to say that if EHRs work as intended, and if they are are used properly, then they can help reduce risks and improve patient outcomes...but both those "ifs" are not certainties by any means. Thus the risk for malpractice and other legal risks.
The issue became visible last fall during the U.S Ebola scare, when the hospital with patient zero initially blamed its EHR for missing key information that would have helped them spot the proper diagnosis earlier, only to be firmly rebutted by Epic, the EHR vendor. The facts appear to be that the problem was not the EHR itself but the workflow and how information in the EHR got viewed by whom (e.g., nurses notes were not readily visible to doctors).
I'll bet Epic felt it dodged a bullet, but they shouldn't be too complacent. EHR vendors represent deeper pockets than most providers, which makes them a tempting target for lawsuits. As Computerworld put it in an article last month, Lawyers smell blood in electronic medical records.
The article cited Keith Klein, a professor of medicine at UCLA, as describing four cases where the judgments were over $7.5 million because the data in the EHR couldn't be trusted. Dr. Klein told Computerworld: "There are attorneys now looking for a clean case to sue the vendor. This is reality. It is not theoretical."
Deep pockets, here we come.
In a related post, Dr. Jeffrey Guterman, another professor at UCLA, criticizes the push for meaningful use, suggesting that "meaningful users" are more important. Dr. Guterman believes that once HITECH passed, EHR vendors made a land grab for market share, with the unintended consequence of diverting resources devoted to R&D and technology advancement.
Dr. Guterman further says that most EHR systems were built from billing platforms and/or use database structures that are well over thirty years old. These lead directly to the interoperability issues that I've written about before, and which helps explain the EHR vendors' thirst for market share: once they get a customer, they know how difficult it will be for them to ever leave.
"Information blocking" is the new term being used for this intentional desire to confine patient information to a specific EHR platform. ONC recently released a requested report on the topic to Congress, acknowledging that the practice is happening. ONC also detailed the actions that it is already taking, or proposing to take, to address the practice, while noting that "many types of information blocking are beyond the reach of current federal law and programs to address."
A Health Affairs blog post by Julia Adler-Milstein notes both that "ONC makes plain that this behavior will no longer be tolerated," and that the criteria used to define what constitutes information blocking will be very difficult to prove, as the conduct has to be "objectively unreasonable in light of public policy." As she says, "There is no question that the CEO of a large electronic health record vendor would have quite a different definition of “reasonable” than would our National Coordinator for Health IT." Or a hospital CEO.
While ONC, many providers, and even some EHR vendors see a problem, Epic continues to deny there is one. An Epic vice-president told The New York Times, "We do not participate in any activities that could be described as information blocking. To our knowledge, these activities are very rare, if they exist at all."
I'll bet he even said it with a straight face.
Congress inadvertently created the problem, and it can (in theory) pass all the laws ONC suggests to address it, but the truth is that information blocking is likely to continue until information sharing is a financial advantage to providers. That may end up being true within an ACO (although many health systems are trying to accomplish this by making affiliated providers get on their EHR platform), but otherwise there is not much incentive to share.
As Dr. Adler-Milstein concluded, "When the C-suite truly believes that they can be most successful by competing on the basis of sharing and using data, rather than hoarding and controlling data, we will know that we have succeeded." It's just hard to think of too many industries where companies compete by sharing their data.
I keep thinking of a recent Fortune article by Kentaro Toyama, Professor Toyama throws cold water on the hope that technology will help control health costs. His "Law of Amplification" asserts that:
Technology’s primary effect is to amplify, not necessarily to improve upon, underlying human inclinations.That makes me think about those built-on-billing-systems EHRs that Dr. Guterman warned about, and suddenly the issues with EHRs are all too easy to understand. They're not about the patients -- or, at least, not primarily for their benefit -- and their main focus is not assuring better care. The vendors and even their customers would probably disagree with both assertions, but providers are buying the EHRs more to get the federal incentives and to help protect their revenue stream than to improve care. And that is the problem.
Many readers probably recognized that my title referenced Shakespeare's "The first thing we do, let's kill all the lawyers" from Henry VI. I have to admit that, until I looked it up, I assumed it was referring to venial or corrupt lawyers. In fact, it means the opposite: it was spoken by a character trying to overthrow the government and the rule of law.
So it is with EHRs. We shouldn't get caught up in blaming them for their perceived shortcomings and hamstringing their development with more rules. Instead, we should do a better job of creating the appropriate environment for them to rapidly evolve to help improve care.
For previous thoughts on how to do that, try here, here, here, and here.
Wednesday, May 20, 2015
Not One Penny More
If you've been to a doctor's office or seen some other health care provider, chances are you've had to sign a patient consent form that, among other things, makes you promise that whatever they end up doing to you, and however much they choose to charge you for it, you're responsible for paying. If your health plan happens to get you a negotiated rate and perhaps covers some of the expenses, that's great, but the provider is still looking to you for payment.
Maybe you shouldn't be so quick to sign.
I don't know which is worse: that providers don't think they should tell you in advance what they plan to do to you, or that they don't want to admit how much they will try to charge for it. Either way, it'd be a great reality show to watch practice administrators trying to defend the vagueness of their promise versus the expected specificity of yours.
Honestly, why do we keep falling for this?
I thought about this when reading Kaiser Health News' Radical Approach to Huge Hospital Bills: Set Your Own Price. It profiles benefits consulting company ELAP Services, which goes beyond traditional services like benefits design, direct contracting, and medical bill reviews by also vowing to go to court if necessary to support their customers in disputes over medical bills.
The problem is well documented. Charges are out of control. There is often no meaningful connection between providers' "charges" and the negotiated prices they've agreed to with third party payors. As long as you have insurance and stay in-network, you don't usually care, because you get the benefit of those negotiated rates. But if you don't have insurance or use -- knowingly or unknowingly -- out-of-network providers, those charges become very important, since you end up being responsible for all or most of them.
A number of states, including New York, have already taken legislative action on the problem, while others, such as New Jersey, are considering doing the same. Still, between their lobbyists and billing experts, I fear that providers will figure out ways around such legislative efforts. That's why I'm intrigued by ELAP's in-your-face approach.
The KHN article cited the example where an employee of one of ELAP's clients had back surgery and was billed $600,000 by the hospital. ELAP analyzed the hospital's Medicare's cost reports, and advised the client to pay a much lower amount. "We wrote a check to the hospital for $28,900 and we never heard from them again," said the client's CFO.
ELAP CEO Steve Kelly says "overwhelmingly, the providers just accept the payment." ELAP has clients write their process for determining reimbursements into benefit plan documents to give greater legal weight. They already have a federal court ruling in support of their process. The contract requires them to defend patients from any collections efforts, in return for a percentage of the savings.
I'd love to know how many times ELAP has had to go to court, and what their success rate has been. But, boy, I'd hate to be the lawyer who has to defend some of the outlandish charges that patients may be billed.
Most health plans base their out-of-network payments on "reasonable charges," which is how most health insurance plans worked prior to the advent of network plans like PPOs, when negotiated payment rates became the norm. Many health plans, such as Aetna and United Healthcare use a service called Fair Inc. to set their "reasonable" limits. Fair was created as part of a settlement with the New York Attorney General, who believed health plans were artificially understating what they used as their reasonable charges (which, of course, meant their members ended up on the hook for more of the costs).
Whether it has worked as intended is not entirely clear, but what is clear is that providers can come after patients for amounts not paid out-of-network by the health plans, all the way up to billed charges, not just to the "reasonable charges."
What I want to know is, if health plans truly believe their limits on charges are reasonable, why don't more of them act like ELAP when providers' charges exceed them? I.e., why aren't they volunteering to stand with the patient -- their customer -- and fight balance billing by providers, in court, if necessary?
ELAP makes it clear whose side they are on; health plans, not so much.
Of course, doing so would give providers yet one more reason for them to distrust health plans, but it's not like there's much trust now. The recent ReviveHealth National Payor & Trust Survey pegged average provider trust of payors at 51.8 out of 100, with a high of 62.7 (Cigna) and a low of 40.5 (UHC), with all three of those results down from last year.
Both payors and providers should be focusing on earning the trust of their customers rather than each other. Health plans have long received low trust marks from consumers, but health care providers are not immune either. Research suggests that U.S. patients' trust in the medical profession has "plummeted" in recent years, and that the U.S. has one of the lowest public trust levels for doctors. Concern about doctors' motivations was cited as a reason for this lack of trust, and I have to blame this at least in part on this problem with excessive charges.
I view the charge structure of most providers as a pernicious symptom of much of what is wrong with our health care system. They rarely have much to do with either actual costs or market forces, and they reflect an arrogant attitude that consumers are there to be gouged as much as possible. Or, more charitably, if not arrogance, then a certain benign neglect to patients' financial well-being. The attitude leads to the incomprehensible bills that patients often received -- what do they care if patients understand them?
Then again, if we didn't have provider networks at all, we might be more able to force providers to compete on price and quality, and to give consumers more and better options. Then we wouldn't have this problem.
I'd love to see a health plan whose EOBs not only detailed how much they were paying and how much of the remaining balance the consumer had to pay, but also said, "by the way, we think $X is the most your provider should charge you for this service, and we don't think you should pay a penny more. If they try to charge you more, let us know and we'll help you fight it."
Now that would be a health plan that consumers would think more of, one that is truly on their side. Oscar, are you listening?
Maybe you shouldn't be so quick to sign.
I don't know which is worse: that providers don't think they should tell you in advance what they plan to do to you, or that they don't want to admit how much they will try to charge for it. Either way, it'd be a great reality show to watch practice administrators trying to defend the vagueness of their promise versus the expected specificity of yours.
Honestly, why do we keep falling for this?
I thought about this when reading Kaiser Health News' Radical Approach to Huge Hospital Bills: Set Your Own Price. It profiles benefits consulting company ELAP Services, which goes beyond traditional services like benefits design, direct contracting, and medical bill reviews by also vowing to go to court if necessary to support their customers in disputes over medical bills.
The problem is well documented. Charges are out of control. There is often no meaningful connection between providers' "charges" and the negotiated prices they've agreed to with third party payors. As long as you have insurance and stay in-network, you don't usually care, because you get the benefit of those negotiated rates. But if you don't have insurance or use -- knowingly or unknowingly -- out-of-network providers, those charges become very important, since you end up being responsible for all or most of them.
A number of states, including New York, have already taken legislative action on the problem, while others, such as New Jersey, are considering doing the same. Still, between their lobbyists and billing experts, I fear that providers will figure out ways around such legislative efforts. That's why I'm intrigued by ELAP's in-your-face approach.
The KHN article cited the example where an employee of one of ELAP's clients had back surgery and was billed $600,000 by the hospital. ELAP analyzed the hospital's Medicare's cost reports, and advised the client to pay a much lower amount. "We wrote a check to the hospital for $28,900 and we never heard from them again," said the client's CFO.
ELAP CEO Steve Kelly says "overwhelmingly, the providers just accept the payment." ELAP has clients write their process for determining reimbursements into benefit plan documents to give greater legal weight. They already have a federal court ruling in support of their process. The contract requires them to defend patients from any collections efforts, in return for a percentage of the savings.
I'd love to know how many times ELAP has had to go to court, and what their success rate has been. But, boy, I'd hate to be the lawyer who has to defend some of the outlandish charges that patients may be billed.
Most health plans base their out-of-network payments on "reasonable charges," which is how most health insurance plans worked prior to the advent of network plans like PPOs, when negotiated payment rates became the norm. Many health plans, such as Aetna and United Healthcare use a service called Fair Inc. to set their "reasonable" limits. Fair was created as part of a settlement with the New York Attorney General, who believed health plans were artificially understating what they used as their reasonable charges (which, of course, meant their members ended up on the hook for more of the costs).
Whether it has worked as intended is not entirely clear, but what is clear is that providers can come after patients for amounts not paid out-of-network by the health plans, all the way up to billed charges, not just to the "reasonable charges."
What I want to know is, if health plans truly believe their limits on charges are reasonable, why don't more of them act like ELAP when providers' charges exceed them? I.e., why aren't they volunteering to stand with the patient -- their customer -- and fight balance billing by providers, in court, if necessary?
ELAP makes it clear whose side they are on; health plans, not so much.
Of course, doing so would give providers yet one more reason for them to distrust health plans, but it's not like there's much trust now. The recent ReviveHealth National Payor & Trust Survey pegged average provider trust of payors at 51.8 out of 100, with a high of 62.7 (Cigna) and a low of 40.5 (UHC), with all three of those results down from last year.
Both payors and providers should be focusing on earning the trust of their customers rather than each other. Health plans have long received low trust marks from consumers, but health care providers are not immune either. Research suggests that U.S. patients' trust in the medical profession has "plummeted" in recent years, and that the U.S. has one of the lowest public trust levels for doctors. Concern about doctors' motivations was cited as a reason for this lack of trust, and I have to blame this at least in part on this problem with excessive charges.
I view the charge structure of most providers as a pernicious symptom of much of what is wrong with our health care system. They rarely have much to do with either actual costs or market forces, and they reflect an arrogant attitude that consumers are there to be gouged as much as possible. Or, more charitably, if not arrogance, then a certain benign neglect to patients' financial well-being. The attitude leads to the incomprehensible bills that patients often received -- what do they care if patients understand them?
Then again, if we didn't have provider networks at all, we might be more able to force providers to compete on price and quality, and to give consumers more and better options. Then we wouldn't have this problem.
I'd love to see a health plan whose EOBs not only detailed how much they were paying and how much of the remaining balance the consumer had to pay, but also said, "by the way, we think $X is the most your provider should charge you for this service, and we don't think you should pay a penny more. If they try to charge you more, let us know and we'll help you fight it."
Now that would be a health plan that consumers would think more of, one that is truly on their side. Oscar, are you listening?
Wednesday, May 13, 2015
Just Along for the Ride
Admit it: when it comes to our health, most of us want something done to/for us. Give us a pill, a procedure, a test. We don't expect to leave a doctor's office with something we're supposed to do (like eat better or get more exercise), or, if we do, all-too-often we end up ignoring it.
If managing our health was like driving a car, most of us would be in the passenger's seat, maybe even the back seat.
I was reminded of this analogy when I read Atul Gawande's latest provocative piece -- Overkill -- in The New Yorker. In it, he describes the "avalanche" of unnecessary care that our health system generates. Nothing he talks about should come as a surprise to anyone who only even mildly follows health care, but yet the problem remains.
At least we're talking about it (including, I'm pleased to remind readers, a post I did last month).
Dr. Gawande recaps some of the recent research on how much unnecessary care there is, which always tend to end up in the ballpark of about a third. He did a sample of eight of his own patients' histories, and found that seven of them had, at some point, received what he believed was clearly unnecessary and/or inappropriate care. It might have been a small, non-random study, but the point is that eventually we're all likely to be subject to such care. Most times no real harm comes of it, but it only takes one bad outcome to severely impact our health.
He cites the examples of the hundreds of millions of scans and billions of lab tests, noting that: "Often these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish." That can lead to more testing and possibly procedures, and sometimes to damage from them (e.g., radiation exposure from excess CT scans).
I also liked Dr. Gawande's discussion of our we treat cancer. He refers to H. Gilbert Welsh's Less Medicine, More Health, Welsh believes that we treat cancers as rabbits, which we want to catch quickly, when in fact many are more like turtles. They're not going anywhere, at least not in any hurry. With our vastly increased testing we're finding more cancers at an early stage, and both patients and providers tend to want to take action.
Early detection is not always better. Dr. Gawande points out the example of thyroid cancers. We've tripled the detection and removal of them in the past two decades, but haven't impacted the death rate at all. Maybe those patients' quality of life has improved, but many of them faced anxiety and procedures that weren't necessary -- and that may have caused harm.
The reasons for the over-treatment is no surprise. As Dr. Gawande says, as a physician, he's more worried about doing too little than too much, since it is the things he should have done that come back to haunt him. Plus, of course, most of our providers still get paid for doing more, not less.
And we just allow this overkill to happen to us.
I was further reminded of the passenger metaphor when I recently read Missing Microbes, by Martin Blaser, M.D. Dr, Blaser makes the case that many of our "modern plagues" -- obesity, diabetes, allergies, asthma, and many others -- may be attributable to the disruption in our microbiomes caused by overuse of antibiotics.
For anyone in need of a quick refresher, scientists have found that our bodies are thoroughly colonized by hosts of bacteria. Indeed, it is estimated that 99% of the unique genes in our bodies actually belong to "them," and only 1% to "us." Our guts are a particularly rich area of concentration for bacteria, but virtually every part of our bodies has some.
Since we began using antibiotics in the middle of the 20th century, we've increasingly become exposed to them, allowing us to beat back infections that once would have killed millions. They've been a blessing, but may also be a curse in disguise.
The problem of antibiotic resistance, in which continued exposure to antibiotics creates strains of bacteria resistant to them (e.g., most recently typhoid) is now well known, but Dr. Blaser believes an even more important but less obvious problem is how we're disrupting the ecological balance bacteria and our bodies had achieved throughout our mutual evolution.
The book documents some of the evidence for the association between changes in the microbiome and the various "lifestyle" epidemics that we are experiencing.
If it sounds crazy, remember that until a generation or so ago it was "known" that ulcers were caused by stress, and were treated by trying to reduce stress, change to bland diets and sometimes surgery. In the 1980's evidence began to accumulate that a bacteria called H. Pylori was actually the culprit most of the time, so we started treating ulcers by attacking it.
Just to show how complicated the balance is, though, it appears that reducing H. Pylori may help mitigate ulcers but that may then impact stomach cancer or esophageal diseases like GERD.
Dr. Blaser was a pioneer in stressing the importance of our microbiome, and his views are not yet conventional wisdom by any means, but others are joining the band wagon. Just this week researchers at the University of Minnesota confirmed a link between antibiotic use in infants, changes in gut bacteria, and disease later in life. They aren't the first researchers to support Dr Blaser's views, and I suspect they won't be the last.
So when I describe us as passengers in our health, it's not even clear who "us" is. Much of what we think of as our health may rely on the health of millions of bacteria in our microbiome, which modern medicine has long been treating as dangerous interlopers.
Dr. Blaser's work suggests that we may need a new paradigm about what produces good health and how to best achieve it. Last fall I speculated on a health care system without doctors, or at least with less reliance on them, and treatments centered around the microbiome was a prime example.
Dr. Gawande sees a health system much like our current one, but with a more judicious use of care. If Dr. Blaser is right, the health care system of the future might look and act very differently. In either event, when it comes to our health, we need to be more than along for the ride.
If managing our health was like driving a car, most of us would be in the passenger's seat, maybe even the back seat.
I was reminded of this analogy when I read Atul Gawande's latest provocative piece -- Overkill -- in The New Yorker. In it, he describes the "avalanche" of unnecessary care that our health system generates. Nothing he talks about should come as a surprise to anyone who only even mildly follows health care, but yet the problem remains.
At least we're talking about it (including, I'm pleased to remind readers, a post I did last month).
Dr. Gawande recaps some of the recent research on how much unnecessary care there is, which always tend to end up in the ballpark of about a third. He did a sample of eight of his own patients' histories, and found that seven of them had, at some point, received what he believed was clearly unnecessary and/or inappropriate care. It might have been a small, non-random study, but the point is that eventually we're all likely to be subject to such care. Most times no real harm comes of it, but it only takes one bad outcome to severely impact our health.
He cites the examples of the hundreds of millions of scans and billions of lab tests, noting that: "Often these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish." That can lead to more testing and possibly procedures, and sometimes to damage from them (e.g., radiation exposure from excess CT scans).
I also liked Dr. Gawande's discussion of our we treat cancer. He refers to H. Gilbert Welsh's Less Medicine, More Health, Welsh believes that we treat cancers as rabbits, which we want to catch quickly, when in fact many are more like turtles. They're not going anywhere, at least not in any hurry. With our vastly increased testing we're finding more cancers at an early stage, and both patients and providers tend to want to take action.
Early detection is not always better. Dr. Gawande points out the example of thyroid cancers. We've tripled the detection and removal of them in the past two decades, but haven't impacted the death rate at all. Maybe those patients' quality of life has improved, but many of them faced anxiety and procedures that weren't necessary -- and that may have caused harm.
The reasons for the over-treatment is no surprise. As Dr. Gawande says, as a physician, he's more worried about doing too little than too much, since it is the things he should have done that come back to haunt him. Plus, of course, most of our providers still get paid for doing more, not less.
And we just allow this overkill to happen to us.
I was further reminded of the passenger metaphor when I recently read Missing Microbes, by Martin Blaser, M.D. Dr, Blaser makes the case that many of our "modern plagues" -- obesity, diabetes, allergies, asthma, and many others -- may be attributable to the disruption in our microbiomes caused by overuse of antibiotics.
For anyone in need of a quick refresher, scientists have found that our bodies are thoroughly colonized by hosts of bacteria. Indeed, it is estimated that 99% of the unique genes in our bodies actually belong to "them," and only 1% to "us." Our guts are a particularly rich area of concentration for bacteria, but virtually every part of our bodies has some.
Since we began using antibiotics in the middle of the 20th century, we've increasingly become exposed to them, allowing us to beat back infections that once would have killed millions. They've been a blessing, but may also be a curse in disguise.
The problem of antibiotic resistance, in which continued exposure to antibiotics creates strains of bacteria resistant to them (e.g., most recently typhoid) is now well known, but Dr. Blaser believes an even more important but less obvious problem is how we're disrupting the ecological balance bacteria and our bodies had achieved throughout our mutual evolution.
The book documents some of the evidence for the association between changes in the microbiome and the various "lifestyle" epidemics that we are experiencing.
If it sounds crazy, remember that until a generation or so ago it was "known" that ulcers were caused by stress, and were treated by trying to reduce stress, change to bland diets and sometimes surgery. In the 1980's evidence began to accumulate that a bacteria called H. Pylori was actually the culprit most of the time, so we started treating ulcers by attacking it.
Just to show how complicated the balance is, though, it appears that reducing H. Pylori may help mitigate ulcers but that may then impact stomach cancer or esophageal diseases like GERD.
Dr. Blaser was a pioneer in stressing the importance of our microbiome, and his views are not yet conventional wisdom by any means, but others are joining the band wagon. Just this week researchers at the University of Minnesota confirmed a link between antibiotic use in infants, changes in gut bacteria, and disease later in life. They aren't the first researchers to support Dr Blaser's views, and I suspect they won't be the last.
So when I describe us as passengers in our health, it's not even clear who "us" is. Much of what we think of as our health may rely on the health of millions of bacteria in our microbiome, which modern medicine has long been treating as dangerous interlopers.
Dr. Blaser's work suggests that we may need a new paradigm about what produces good health and how to best achieve it. Last fall I speculated on a health care system without doctors, or at least with less reliance on them, and treatments centered around the microbiome was a prime example.
Dr. Gawande sees a health system much like our current one, but with a more judicious use of care. If Dr. Blaser is right, the health care system of the future might look and act very differently. In either event, when it comes to our health, we need to be more than along for the ride.
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