Category Archives: policy

healthcare, policy, politics

Doggett backs in Professor Halton

In the context of recent experiences, this analysis does not stand up:

Blaming a public servant – even one as senior and reputedly influential as Professor Halton – for a bad Government decision not only lets Minister Peter Dutton off the hook on this issue, it undermines the fundamental accountability of the Government.  Both critics and supporters of the Government and its 2014/15 Budget initiatives should focus on ensuring Ministers are fully answerable to the community for their decisions and not look to public servants as scapegoats.

Also annoying to see Terry continuing to dig a hole:

Former Liberal adviser Terry Barnes took to Twitter over the weekend to publicly criticise Department of Health Secretary Professor Jane Halton for her role in the Government’s GP co-payment Budget initiative.  Among his comments were “Jane Halton was chief designer of the GP co-pay package. Send her to Geneva, not Finance’.

 

http://blogs.crikey.com.au/croakey/2014/06/02/senate-estimates-what-they-reveal-about-federal-budget-201415/

Senate Estimates – what they reveal about Federal Budget 2014/15

JENNIFER DOGGETT | JUN 02, 2014 4:20PM |  | PRINT
The Budget sittings of Senate Estimates are on again this week with senior bureaucrats filing into the various committee rooms of the Senate to be grilled by Opposition and minor party Senators, desperate to find some additional details, figures, omissions or politically sensitive procedural issues in order maintain the Budget rage for as long as possible.

Estimates are an important part of Government accountability and transparency processes and can often reveal some key details of funding measures which may not have been disclosed in the official Budget papers or, through some political ‘oversight’, left out of the Budget night communications.

For example, last week Senator Penny Wong relentless pursued a line of inquiry on the cuts to Indigenous health services – revealing that despite the significantly poorer status of Aboriginal and Torres Strait Islander Australians, services to them were being cut by over half a billion dollars with the future a broad range of health, social welfare and education programmes still in budgetary limbo.

Senator Rachel Siewert has also been active in Estimates on this issue sending out a number of Tweets, including the following:

OMG Govt health ppl responsible for Aboriginal Medical Services haven’t modelled impact of $7 GP co-payment on those services

Govt cutting $165.8m from Aboriginal health to put in Health Research Future Fund – as if the health problems aren’t urgent now
 
Sorry apparently these aren’t cuts to Aboriginal health programmes they are pauses

Due to its potential for ferretting out nuggets of media-friendly and politically damaging information, the Estimates process has become a much more intense and partisan process than perhaps it was ever intended to be.  With politicians interrogating public servants for their own political ends and using the opportunity for some grandstanding of their own, the pressure on bureaucrats to maintain their a-political positions is intense. Surely it can’t be easy for a senior public servant, no doubt impacted themselves by Government cuts to the bureaucracy and worried about their own job security, to have to explain Government policies and funding cuts they often had little influence over and in many cases don’t agree with?

Despite the potential for ‘free and fearless advice’ to be overshadowed by political machinations, it’s important not to blur the lines between the political and bureaucratic processes when looking at the Senate Estimates process.  Former Liberal adviser Terry Barnes took to Twitter over the weekend to publicly criticise Department of Health Secretary Professor Jane Halton for her role in the Government’s GP co-payment Budget initiative.  Among his comments were “Jane Halton was chief designer of the GP co-pay package. Send her to Geneva, not Finance’.

I am not privy to the communications between the Department and the Minister’s Office on the co-payment issue and I am not a fan of this fundamentally flawed policy.  However, regardless of the advice Professor Halton and her Department provided to the Minister, she cannot be held in any way responsible for the Government’s policy decisions on this, or any other, issue.  As an unelected public servant, her role is to give advice and it is the role of the Government to then act on this advice, if it so wishes. Fundamental to our Westminster system of Government is the accountability of Ministers for their decisions and the ability of the public to remove them from office via an election if these decisions prove unpopular. This accountability exists regardless of the quality of the advice they receive on the issue (although it has to be said there were plenty of people around who could have pointed out the problems with the co-payment policy).

Blaming a public servant – even one as senior and reputedly influential as Professor Halton – for a bad Government decision not only lets Minister Peter Dutton off the hook on this issue, it undermines the fundamental accountability of the Government.  Both critics and supporters of the Government and its 2014/15 Budget initiatives should focus on ensuring Ministers are fully answerable to the community for their decisions and not look to public servants as scapegoats.

facts & data points, health market quality, healthcare, policy, politics

Endoscopic overservicing

 

Upper endoscopies may bilk Medicare

May 24, 2014 | By 

http://www.forbes.com/sites/peterubel/2014/05/22/are-gastroenterologists-scoping-for-dollars-on-medicare-patients/

Peter Ubel

Peter Ubel, Contributor

I explore medical controversies thru behavioral econ and bioethics.

5/22/2014 @ 11:23AM |801 views

Inappropriate Medicare Incentives Lead To Unnecessary Subspecialty Procedures

Comment Now

Sometimes people flat out need cameras shoved down into their stomachs.  A long history of reflux disease, for example, could prompt a gastroenterologist to perform an “upper endoscopy”—to run a thin tube down the patient’s throat in order to view their esophagus and stomach and look for signs of serious illness.  Medicare has correctly decided that such upper endoscopies are valuable medical tests, and reimburse physicians relatively generously for performing them.  But what should Medicare do when gastroenterologists unnecessarily repeat these tests in patients who do not show signs of serious illness on their first exam?

I became aware of this issue after reading an article in the Annals of Internal Medicine by Pohl and colleagues.  Pohl glanced at billing data from a random sample of almost 1 million Medicare enrollees. (I am pleased with myself when I pull together a study of a few hundred patients.  Perhaps I won’t be so pleased in the future.)

Pohl and colleagues analyzed how many patients received more than one upper endoscopy within a three year period.  They then tried to figure out how often these repeat procedures were necessary, because of abnormalities discovered in the initial exam.

Let’s start with the bad news.  Among those patients who should have received repeat tests, only half did so.  That means even when doctors found bad things that needed to be followed up, it was practically a flip of a coin whether they would do so.

Now for the worse news.  Among those who should not have received a follow-up test, a full 30% did, for a total of 20,000 such tests in this population.  Here is a picture summarizing the results:

repeat upper endoscopies

Here is another way to look at these results.  Among patients receiving upper endoscopies, the majority –54%—should not have received these tests.

Now for some back-of-the-envelope math.  The sample of patients Pohl and colleagues looked at made up 5% of the Medicare population.  That means if you take their estimates of how many gastroenterologists performed unnecessary upper endoscopies over the three year period of their study, and multiply that estimate by 20, you end up with 4 million unnecessary endoscopies nationwide.  With the average costs of such a procedure being around $3,000, that amounts to $1.2 billion of our tax dollars wasted on an unnecessary and, I should mention, uncomfortable and potentially harmful procedure.  (Warning: I don’t know what Medicare pays for this test.  But we are still talking hundreds of millions of dollars, in a best case scenario.)

In an editorial accompanying the Annals study, a gastroenterologist bemoaned these unnecessary procedures and recommended several steps we could take to reduce such testing.  First, the editorialist said we should help physicians better understand when they should and should not use such procedures.  Second, he said we “must also educate patients about the modest yield” of such tests.

I find this last idea…what’s a nice way to put this…highly naïve.  (Haive?)

What we need to do is to stop paying doctors for unnecessary tests.  Or alternatively, we need to pay doctors in ways that reduce their incentive to perform unnecessary tests, like lump sums to take care of all of their patients’ needs.

While some gastroenterologists may be cynically scoping patients for dollars—performing questionable tests because it pays for their kid’s private school tuition—I expect most believe such testing is in their patient’s best interests.  We need an incentive system that forces them to think more carefully about when—or whether—these expensive tests are necessary.

 

healthy habits, nutrition, policy, politics, rapid learning health systems, research methodology

The case for eating steak and cream

 

 

http://www.economist.com/news/books-and-arts/21602984-why-everything-you-heard-about-fat-wrong-case-eating-steak-and-cream

Economist Book Review

The Case For Eating Steak and Cream

Shifting the argument

The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet. By Nina Teicholz. Simon & Schuster; 479 pages; $27.99. Buy from Amazon.com,Amazon.co.uk

“EATING foods that contain saturated fats raises the level of cholesterol in your blood,” according to the American Heart Association (AHA). “High levels of blood cholesterol increase your risk of heart disease and stroke.” So goes the warning from the AHA, the supposed authority on the subject. Governments and doctors wag their fingers to this tune the world over. Gobble too much bacon and butter and you may well die young. But what if that were wrong?

Nina Teicholz, an American journalist, makes just that argument in her compelling new book, “The Big Fat Surprise”. The debate is not confined to nutritionists. Warnings about fat have changed how food companies do business, what people eat, and how and how long they live. Heart disease is the top cause of death not just in America, but around the world. The question is whether saturated fat is truly to blame. Ms Teicholz’s book is a gripping read for anyone who has ever tried to eat healthily.

The case against fat would seem simple. Fat contains more calories, per gram, than do carbohydrates. Eating saturated fat raises cholesterol levels, which in turn is thought to bring on cardiovascular problems. Ms Teicholz dissects this argument slowly. Her book, which includes well over 100 pages of notes and citations, covers decades of nutrition research, including careful explorations of academics’ methodology. This is not an obvious page-turner. But it is.

Ms Teicholz describes the early academics who demonised fat and those who have kept up the crusade. Top among them was Ancel Keys, a professor at the University of Minnesota, whose work landed him on the cover of Time magazine in 1961. He provided an answer to why middle-aged men were dropping dead from heart attacks, as well as a solution: eat less fat. Work by Keys and others propelled the American government’s first set of dietary guidelines, in 1980. Cut back on red meat, whole milk and other sources of saturated fat. The few sceptics of this theory were, for decades, marginalised.

But the vilification of fat, argues Ms Teicholz, does not stand up to closer examination. She pokes holes in famous pieces of research—the Framingham heart study, the Seven Countries study, the Los Angeles Veterans Trial, to name a few—describing methodological problems or overlooked results, until the foundations of this nutritional advice look increasingly shaky.

The opinions of academics and governments, as presented, led to real change. Food companies were happy to replace animal fats with less expensive vegetable oils. They have now begun abolishing trans fats from their food products and replacing them with polyunsaturated vegetable oils that, when heated, may be as harmful. Advice for keeping to a low-fat diet also played directly into food companies’ sweet spot of biscuits, cereals and confectionery; when people eat less fat, they are hungry for something else. Indeed, as recently as 1995 the AHA itself recommended snacks of “low-fat cookies, low-fat crackers…hard candy, gum drops, sugar, syrup, honey” and other carbohydrate-laden foods. Americans consumed nearly 25% more carbohydrates in 2000 than they had in 1971.

In the past decade a growing number of studies have questioned the anti-fat orthodoxy. Ms Teicholz’s book follows the work of Gary Taubes, a science journalist who has cast doubts on the link between saturated fat and health for well over a decade—and been much disparaged for his pains. There is increasing evidence that a bigger culprit is most likely insulin, a hormone; insulin levels rise when one eats carbohydrates. Yet even now, with more attention devoted to the dangers posed by sugar, saturated fat remains maligned. “It seems now that what sustains it,” argues Ms Teicholz, “is not so much science as generations of bias and habit.”

health market quality, healthcare, policy, politics, rapid learning health systems

Cth Fund: 40% of patient outcomes from social factors

Report: 1749_Bachrach_addressing_patients_social_needs_v2

http://www.commonwealthfund.org/publications/fund-reports/2014/may/addressing-patients-social-needs

As much as 40 percent of patient outcomes can be attributed to factors such as income, educational attainment, access to food and housing, and employment status—and low-income populations are particularly affected.

New Report Shows How Targeting Patients’ Social Needs Is Critical to Improving Quality and Reducing Costs

As public and private payers increasingly hold providers accountable for their patients’ health and health care costs and link payments to outcomes, providers are developing strategies to address the social factors that play so large a role in people’s health. As much as 40 percent of patient outcomes can be attributed to factors such as income, educational attainment, access to food and housing, and employment status—and low-income populations are particularly affected.

A new report prepared by Manatt Health Solutions for The Commonwealth Fund, The Skoll Foundation, and The Pershing Square Foundation explores the impact of social needs on health and the costs of care and identifies evidence-based strategies and interventions that can help providers target patients’ social needs, improve health, and reduce spending. The report examines payment models that incentivize or require providers to address not just their patients’ clinical needs but their social needs as well.

For providers unable or unwilling to invest in social interventions, the report suggests alternative opportunities for funding them. Research indicates that in addition to improving patient health, investing in these interventions can enhance patient satisfaction and loyalty, as well as satisfaction and productivity among providers.

Visit commonwealthfund.org to read Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment and learn about the variety of tools available to providers and the range of effective programs in the U.S. and abroad.

 

Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment

Extensive research documents the impact of social factors such as income, educational attainment, access to food and housing, and employment status on the health and longevity of Americans, particularly lower-income populations. These findings attribute as much as 40 percent of health outcomes to social and economic factors. Asthma is linked to living conditions, diabetes-related hospital admissions to food insecurity, and greater use of the emergency room to homelessness.

These findings are not lost on health care providers: 80 percent of physicians conclude that addressing patients’ social needs is as critical as addressing their medical needs. Yet until recently, providers rarely addressed patients’ unmet social needs in clinical settings.

However, changes in the health care landscape are catapulting social determinants of health into an on-the-ground reality for providers. The Affordable Care Act is expanding insurance coverage to millions more low- and modest-income individuals, and, for many, social and economic circumstances will define their health. Six years after analysts introduced the concept of the “Triple Aim,” its goals of improved health, improved care, and lower per capita cost of care have become the organizing framework for the health care system. As a result, growing numbers of providers are concluding that investing in interventions addressing their patients’ social as well as clinical needs makes good business sense.

The Economic Rationale for Investing in Social Interventions

Informed by the Triple Aim, public and private payers are introducing payment models that hold providers financially accountable for patient health and the costs of treatment. These models—including capitated, global, and bundled payments, shared savings arrangements, and penalties for hospital readmissions—give providers economic incentives to incorporate social interventions into their approach to care. For example, in October 2012, the Centers for Medicare and Medicaid Services penalized 77 percent of safety-net hospitals for excess readmissions of patients with heart attack, heart failure, or pneumonia. Meanwhile a review of 70 studies found that unemployment and low income were tied to a higher risk of hospital readmission among patients with heart failure and pneumonia.

To be certified as a patient-centered medical home (PCMH) or Medicaid health home, providers must integrate social supports into their care models. And these certifications almost always trigger higher levels of reimbursement. More than 40 states have adopted PCMH programs, providing important funding opportunities for qualified providers. Even if new payment models do not require social interventions, many providers have concluded that they are essential to achieving quality metrics and earning available revenue.

Beyond these direct economic benefits, providers that incorporate social supports into their clinical models can also reap indirect economic benefits. Patient satisfaction rises when providers address patients’ social needs, engendering loyalty. Patient satisfaction can also affect the amount of shared savings a provider receives from payers. Providers that include social supports in their clinical models also report improved employee satisfaction. And interventions that address social factors allow clinicians to devote more time to their patients, allowing them to see more patients and improving satisfaction among both patients and clinicians.

Strategies to Meet Patients’ Social Needs

A range of tools, both broad and targeted, are available to providers to address patients’ unmet social needs. Broad interventions—usually provided at primary care clinics—link clinic patients to local resources that can address their unmet social needs. For example:

  • Health Leads, which operates in hospital clinics and community health centers in six cities, enables health care providers to write prescriptions for their patients’ basic needs, such as food and heat. Trained volunteers who staff desks at the hospitals and clinics connect patients to local resources to address those needs. Across all sites, Health Leads volunteers addressed at least one need of 90 percent of patients referred to them.
  • Medical-Legal Partnerships (MLPs) place lawyers and paralegals at health care institutions to help patients address legal issues linked to health status. This program has had marked success: an MLP in New York City targeting patients with moderate to severe asthma found a 91 percent decline in emergency department visits and hospital admissions among those receiving housing services.

Targeted interventions, in contrast, link individuals with chronic or debilitating medical conditions to social supports as part of larger care management efforts. For example, in the Seattle-King County Healthy Homes Project, community health workers conduct home visits to low-income families with children with uncontrolled asthma. Urgent care costs for participants in a high-intensity intervention were projected to be up to $334 per child lower than among those receiving a less intensive intervention. The share of individuals using urgent care services also fell by almost two-thirds during the intervention.

Looking Forward

As more low-income people gain health care coverage, evidence on which interventions are most cost-effective in addressing their social needs and improving their health will grow, and value-based reimbursement will become standard across payers. With these changes in the health care landscape, the economic case for provider investment in social interventions will become ever more compelling.

This publication was supported in partnership with The Skoll Foundation and The Pershing Square Foundation.

complex adaptive systems, data saving lives, facts & data points, healthcare, healthy habits, nutrition, policy, politics, rapid learning health systems

Economist Daily Chart: Peak Fat

Worryingly, the study—led by the Institute of Health Metrics and Evaluation at the University of Washington—showed that children are fattening at a faster pace than adults. Last week the World Health Organisation set up a new commission to curb child obesity. But it will be some time yet before the world reaches peak fat.

http://www.economist.com/blogs/graphicdetail/2014/05/daily-chart-19?fsrc=scn/fb/wl/dc/peakfat

Daily chart

Peak fat

20140531_gdc156_0 Economist Peak Fat

WAISTLINES are widening everywhere. The percentage of adults who are overweight or obese has swelled from 29% in 1980 to 37% in 2013, according to a new study in the Lancet. People in virtually all nations got larger, with the biggest expansions seen in Africa, the Middle East and New Zealand and Australia. The chunkiest nations overall are found in the tiny Pacific islands and Kuwait, where over three-quarters of adults are overweight and over half are obese. And the world is unlikely to slim down soon. While the rate of increase has slowed in the rich world, it is still rising in poorer countries, where two-thirds of the world’s 2.1 billion overweight adults live. China is home to the largest number anywhere—335m, more than the population of America. This is not just because of its sheer size, but also because economic growth led to cellulite growth: a quarter of adults are now overweight compared with one in ten in 1980.Mexicans just outweigh neighbouring Americans. In both countries, two-thirds of people could lose a pound or two, though more Americans are obese. Agreeing on how to combat the problem is tricky, given that experts continue to bicker on what, precisely, makes us fat. Worryingly, the study—led by the Institute of Health Metrics and Evaluation at the University of Washington—showed that children are fattening at a faster pace than adults. Last week the World Health Organisation set up a new commission to curb child obesity. But it will be some time yet before the world reaches peak fat.

complex adaptive systems, health market quality, healthcare, policy, politics, rapid learning health systems

Deeble Inst: Jury still out on P4P

 

PDF: deeble_issues_brief_no_6_partel_k_can_we_improve_the_health_system_with_performance_reporting

The jury is still out on pay-for-performance and other financial incentive mechanisms

Date:

Wed, 28/05/2014

Spokesperson:

Australian Healthcare and Hospitals Association (AHHA)

Can we improve the health system with pay-for-performance? is the latest Health Policy Issues Brief released by the Australian Healthcare and Hospitals Association’s Deeble Institute for Health Policy Research. Outlining Australian and international experiences with pay-for-performance, the brief unpacks the latest research evidence and implications for policymakers.

“The healthcare system is moving toward greater efficiency, transparency and accountability, and this trend is not likely to change,” Alison Verhoeven, Chief Executive of the AHHA said today. “To meet these goals, a number of financing reforms have been implemented across its health system, but it is unclear where the reform process is now headed.”

“We need to remember there is no single fix to improve service delivery and patient outcomes, to ensure financial sustainability and to increase accountability and transparency in a health system,” said Krister Partel, Policy Analyst with the AHHA’s Deeble Institute. “The jury is still out on whether financial incentive mechanisms, such as pay-for-performance, work as intended and deliver value for money, but if we want to go down that route then the research literature is rich in lessons to keep in mind when developing and rolling out pay-for-performance programs.”

“Regardless of how health financing is structured in the future, governments must ensure that changes strengthen the health system and improve public confidence in it,” said Alison Verhoeven.

“The AHHA is proud to support independent research to inform evidence-based policy development, and we look forward to furthering this discussion to maximise the use of health resources and enhance patient care.”

The Australian Healthcare & Hospitals Association represents Australia’s largest group of health care providers in public hospitals, community and primary health sectors and advocates for universal high quality healthcare to benefit the whole community.

Media inquiries:
Alison Verhoeven, Chief Executive, Australian Healthcare and Hospitals Association 0403 282 501

 

health market quality, healthcare, policy, rapid learning health systems

Samsung moving into value-based pharma..?!

Go Samsung… it would be great to see the traditional pharma model disrupted in this way…

A New Era in Value-Driven Pharmaceuticals

A New Era in Value-Driven Pharmaceuticals

0 Responses

By LEONARD KISH & CYNDY NAYER

flying cadeuciiAt the end of March the Amercian College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint statement saying they “will begin to include value assessments when developing guidelines and performance measures (for pharmaceuticals), in recognition of accelerating health care costs and the need for care to be of value to patients.”

You may have heard of value-based medicine, but are we entering a new era of value-based medications or value-driven pharma?

Price transparency is great, but it has be combined with efficacy to get to value (price for the amount of benefit). Medical groups are catching on to how important value assessments are, because if patients can’t afford their medication, they won’t take their medication, and that obviously can turn into poor outcomes.

Twenty-seven percent of American patients didn’t fill a prescription last year according to a Kaiser Family Foundation Survey. This trend seems likely to continue as we move toward higher-deductible plans, where those with insurance can have great difficulty affording medications.

Included in the ACC/AMA statement was a quote from Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine.

“There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed…These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources.”

Spreading risk and payment to different members of the health care value chain is beginning to make it apparent to more people and organizations that resources are finite. Patients and their physicians are starting to ask which treatments are worth the cost and have best likelihood of adherence.

An outgrowth of the move toward digital health and accountable care is that we’re entering every patient into a potential personal clinical trial with their data followed as a longitudinal study, and we can look much more closely at efficacy and adherence and reasons why it happens and why it doesn’t.

It won’t be long before we start to see comparative effectiveness across a variety of treatments and across a variety of populations. When we can connect outcomes data, interventions and costs all in the same picture we begin to see where the value (price against results) is and where it isn’t.


The opportunity to assess value of treatments is bringing non-traditional players into the value-driven pharma arena. Samsung recently announced that they are becoming a drug company. According to Quartz:

“Electronics giant Samsung recently announced a foray into big pharma. The South Korean company is set to invest over $2 billion into biopharmaceuticals—drugs developed from biological sources (e.g. vaccines or gene therapies) as opposed to traditional chemical cocktails—with a focus on creating cheaper versions of existing therapies.”

The real advantage may be access to patient information via mobile. The Quartz article goes on to say:

“…cheapness won’t be Samsung’s only advantage. The company better known for its smartphones could also take advantage of the fact that the pharma industry has been slow to explore mobile health technology…The biotech industry is expected to generate sales of more than $220 billion in five years, Bloomberg reports, and Samsung expects to be taking a $1.8 billion slice of the pie by that time. The company will start by copying Enbrel (an arthritis therapy by Amgen Inc.) and Remicade (Johnson & Johnson’s autoimmune disease treatment) in the next couple of years.”

Samsung is going after arthritis, which Enbrel and Remicade treat. On the surface, this makes sense. Mobile devices are good at tracking and reporting what arthritis impairs– movement– opening up the opportunity for Samsung to close the loop on the effectiveness of their own drugs using their smart phones, tracking progress and improvement.

Pharma has been slow to explore mobile health and data science and slow to leverage social media and other sources of consumer health data effectively for a variety of reasons — some legal (we aren’t responsible for what  we don’t know) and some historical.

This could be a severe disadvantage when looking to leverage existing therapies. Combing through available data from existing research can provide new and cheaper alternatives and, with relatively easy biosimilar approval, see how they compare.

Industry observers are beginning to see this shift and this opportunity, raising alarm bells for big pharma. Are they listening? Over the past month there’s been a virtual outcry for a business model for Pharma that’s based on value. Ernst & Young released a report (.pdf) calling for “radical collaboration.” Dan Munro at Forbes picked out the key line and bold proclamation from the report:

“Almost every life sciences company, regardless of their product or offering, will soon be expected to help change behaviors and deliver better health outcomes.”

EY hits the nail on the head. The combination of value-based care, digital health, and mobile technologies is inevitably driving toward pharma price and evidence transparency and a much better look at the efficacy of various treatments.

Samsung came late to the smart phone market, then experimented with pricing and models before taking over the top place from Apple. Now focusing on biosimilars, Samsung could be following a similar pattern in pharma, testing to see what combinations will work best, powered by ongoing results in a closed feedback-loop system.

Munro asks the question, “To what extent, and in what ways, should pharma companies move beyond the product?” Samsung may be answering that question.

AthenaHealth’s Jonathan Bush echoed the chorus for a new pharma business model in April to a group of pharma executives saying:

“Take every drug you have and organize it by disease by the number of hospital days that could go away…Find the moments that matter financially and clinically.” And further, “Follow up on the prescriptions that are written and make sure the patients get those drugs but also ‘don’t end up in the hospital…Relentlessly follow up on all conditions for success…”

We wonder if “all conditions for success” might also include the condition of affordability.

Jamie Heywood, CEO of PatientsLikeMe, hinted at a value-based medication future in a Nature Medicine interview recently on their new collaboration with Genentech, saying, “What we need to do is get more value for health care, and value means you have competitive outcomes. And that’s what, in our longest dreams, I think PatientsLikeMe begins to bring to bear.”

Samsung is in a unique position to capitalize on social, mobile and, peer interaction. Munro writes in Forbes about a social network/app,Whisper, that is on a fast-track trajectory because of its anonymous posting. Pharma companies could learn great deal of information on the derailing of adherence to treatment by following these posts. And if they don’t, others will fill the void by both providing and applying data to physicians and consumers as well as pulling in data from consumers.

On the data provider and application side, one Startup Health company seeks to provide cost and value transparency of medications at the point of care and bring the price discussion into the exam room.

RxREVU provides data services via API to use peer-reviewed value-based medication decisions for clinicians and their patients (full disclosure, RxREVU is a client of VivaPhi, Leonard Kish’s agency). Because it’s an API, it could also be deployed in the context of a mobile app at the point of care.

This data has always existed, what’s new is the demand for it and how it’s applied.

On the data intake side, more clinically-focused companies such as GoGoHealth are allowing remote EHR intake, improving access to consumer health data, including social determinants of health, to allow for faster, individualized attention by providers (GoGoHealth, also a StartupHealth company, is mentored by Center of Health Engagement, Nayer’s organization).

Part of that is allowing patients to lower barriers to enter the system, getting remote office visits and phone refills. A side product of these kinds of interactions is an understanding of what prevents and what enables patients from continuing on a course of treatment.

As providers and patients assume more of the risk and pay more of the bill, they are seeking solutions that can provide value-based treatment decisions that fit their personalized needs.

The most valuable solutions in a value-driven era will be those that we are able to customize based on information from a wide variety of sources and place the solutions into a contextual format in which patients ultimately have to treat themselves, including financial contexts.

Those that stick with the old pharma model, leaving data and consumers-as-patients out of the mix, will wind up with much less valuable medicine.

Leonard Kish (@leonardkish) is Principal and Co-Founder at VivaPhi, an agency that solves multi-disciplinary business problems involving data science, software, biomedical science, behavioral science, health care, product design, community development, marketing, consumer engagement and organizational design.

Cyndy Nayer (@CyndyNayer) is the founder and CEO of the Center of Health Engagement, an agency promoting strategic investments in health value for employers, health plans and provider organizations.

This post originally appeared in HL7 Standards. 

healthcare, policy, politics, rapid learning health systems

Paul Gross – a fan of Singapore’s Health System policy

 

PDF: gro11102_SingaporeHealthSystem

Singapore’s health system: a model for Australia?

Paul F Gross
Med J Aust 2014; 200 (9): 513.
doi: 10.5694/mja13.11102
 Download PDF
  • Impressive, responsive and innovative, but not without its problems

A book by William Haseltine, a United States medical researcher and founder of the biopharmaceutical company Human Genome Sciences, describes the Singapore health care system — how it works, its financing, its history and its future directions.1 Might it hold any lessons for Australian health care?

The statistics on Singapore’s health care system are impressive. An enviable life expectancy, low infant and child mortality rates, and low rates of mortality from chronic conditions such as cancer and heart disease were achieved with health care expenditures of around US$2787 per capita in 2011 and health expenditure at 4.6% of gross domestic product (GDP), with the government financing about 1.2% of GDP. The sources of financing were employers (35%), government subsidies (25%), out-of-pocket payments (25%), private health insurance (5%), Medisave, a compulsory medical savings scheme (8%) and Medishield, a social insurance scheme for catastrophic medical conditions (2%).

The three original pillars of Singapore financing (Medisave in 1984, Medishield in 1990 and a government-subsidised Medifund to protect low-income citizens in 1993) were innovative and far-seeing. A subsequent fourth pillar (Eldershield in 2002 to pay the high costs of severe disability through insurance, followed by Medishield Silver in 2007) and changes to Medisave in 2006 to fund chronic disease management showed a government unafraid to update the original concepts when gaps appeared.

These pillars judiciously mix taxation, personal cost-sharing, personal savings and social insurance. Taxes and patient charges pay for primary health care and public health services, Medisave creates compulsory savings to pay for acute care, Medishield and ElderShield offer social and private insurance against the catastrophic costs of long-term care, and Medifund and Medifund Silver protect the indigent with targeted government subsidies.

The title of Haseltine’s book suggests that Singapore offers lessons to other nations. That position might be tenable if those nations also had a stable political system with one party in power for a long time, a relatively young population prepared to accept personal responsibility in health care financing, and citizens ready to surrender 40% of their income into a national savings plan (the Central Provident Fund) that funds access to home ownership, higher education, medical care and old-age security.

Unfortunately, there are no compelling insights into why it works. Haseltine applauds the competition between, and quasi-market pricing of, hospitals and medical services as major reasons for Singapore’s impressive health outcomes for a relatively low percentage of GDP. However, he understates the importance of a prescient and interventionist national government listening to the electorate, aiming subsidies at low-income residents and allowing greater risk-pooling of insurance for catastrophic illnesses to embody the ethos of collective responsibility. Furthermore, Singapore can provide uniform care and financing without answering complaints about geographical resource misallocation and the resulting political interference at a subnational level.

What Singapore does better than most nations is watch for signs of gaps in the access to or affordability of health care, building on the existing financing framework and directing subsidies to the neediest first. The August 2013 Medishield Life reform, offering compulsory universal coverage for pre-existing conditions and subsidies for low-income families, exemplifies this.

However, the system still has problems. In a 2012 survey, 72% of Singaporeans indicated that they “cannot afford to get sick these days due to high medical costs”. In a nation where public hospitals offer 80% of acute bed care, allowing competition between hospitals has seen doctors leave the subsidised wards for the poorer citizens to move to unsubsidised, profit-creating “A class” wards. With population ageing, once age-specific rates for the use of services involving expensive medical technologies rise, Singapore will be paying a forecast 6%–8% of GDP for health care.

Even with recent reforms, copayments remain a silent threat to the four pillars model of financing. If you mandate a medical savings scheme with copayments acting as price signals, you accept the risk that rising copayments will restrict access to both necessary and unnecessary care. With copayments and a steady movement of doctors away from the hospital care of the 85% of Singaporeans who live in public housing, Singapore has created a two-class health care system based on a range of amenities tied to charges in public hospitals. Wealth buys more amenities.

What does Haseltine’s book tell Australian politicians? If we were looking for a health financing system that made sense for its sustainability in both 1990 and 2013, Singapore stands out. To get to a similar position, Australia cannot delay reforms to doctor payment, quality-driven hospital reimbursement and price transparency. Affordable health insurance to deal with chronic illness, ageing and disability beyond age 65 years will be a massive challenge until we consider how Singapore’s four pillars model could inform a revamped health and social insurance system in Australia.

And then we have to find political leaders who eschew populist rhetoric and random tinkering, and who can tell us how they intend to achieve affordable excellence in care — a problem that Singapore has never experienced.

Provenance:

Not commissioned; not externally peer reviewed.

healthcare, policy, politics

Medical research fund is a distraction

Brilliant, but highly cynical politics. Tear down universal health care to fund the med tech industry.

http://www.theguardian.com/commentisfree/2014/may/23/joe-hockeys-medical-research-fund-is-nothing-more-than-a-distraction

Joe Hockey’s medical research fund is nothing more than a distraction

If we health and medical researchers do not stand up now, we will be left with the moral blight of having silently colluded in the destruction of universal healthcare

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Scientist in laboratory.
‘We have known for decades that improving health in communities often relies on social change’. Photograph: Francois Lenoir/Reuters

Health is a basic requirement for an individual to lead a good life. Without health you have nothing; when we are sick, it’s difficult to work, to care for others, to participate in the things we enjoy. We seek treatment so we can get back to our normal lives.

Because health is so important to our wellbeing, there is widespread agreement— including among ethicists —that a fair and accessible healthcare system is something that we should pursue. And although the Australian healthcare system is far from perfect, it has provided universal access to healthcare for almost 40 years. A universal healthcare system – one that is open to everyone, whether or not they can afford to pay – is a basic feature of a good and just society.

Tony Abbott and Joe Hockey want us to panic about a “budget emergency”, including the idea that our current health system is unsustainable. Rising healthcare costs pose a challenge to governments everywhere. But this is not a new problem, and will not bring about economic or social catastrophe any time soon.

This amplified threat is being used to justify measures that are now well known: introducing co-payments for GP fees; disestablishing Medicare Locals; transferring health agencies to the department of health with reduced funding; and stripping $80bn in funding from the states, particularly in health and education. This will not only force the states to increase their own goods and services taxes, but reduce the public services they can afford to provide. It will end universal access to health care, make Medicare a mere “safety net”, overwhelm hospitals, and increase the inequities that are increasingly a feature of Australian society.

With breathtaking cynicism, the Coalition has also engaged in the oldest strategy in the magicians’ handbook: distraction. The rabbit they have pulled out of their hat is the $20bn medical research future fund, to be financed – they claim – largely through the new taxes and cuts in health services. This is supposed, we can only presume, to buy the quiescence of health and medical academics and researchers, and to distract citizens from the damage being done to our health system. Given that polls consistently show that Australians strongly support Medicare, it’s likely that the government has underestimated our ability to concentrate on what’s important. There are also strong ethical reasons why the Coalition’s proposed changes are unjustifiable.

Hockey encourages us to imagine that the medical research fund “may well save your life, or that of your parents, or perhaps even the life of your child”. Medical research is clearly a good, and has achieved remarkable breakthroughs in the last century. The medical research future fund may yield benefits. But, as any medical researcher knows, medical research is not a steady production line of cures. It is frequently incremental, with many dead ends, and scope for progress may in fact be diminishing.

More importantly, history shows that, without government intervention, the new treatments produced from medical research are often available only to those who can pay, broadening the gap between rich (who can afford top-shelf care) and poor (who receive little). This means the proposed cuts and fees will burden the least-well-off in the present to fund research that may benefit a few, likely wealthy, people in the future.

More fundamentally, we have known for decades that improving health in communities often relies on social change, rather than high-tech biomedical research. Ready access to GPs and other community-based health care, established vaccinations, good education, affordable healthy food: things like these make a big difference to population health. This is why Hockey’s championing of the medical research future fund as a panacea to service cuts is so offensive. Not only does it overstate the role of medical research in a just healthcare system, but it takes funding away from the agents of social transformation that can effectively and efficiently improve health.

Some health and medical researchers are organising against this unjust policy; others seem willing to support it. As health and medical researchers we could benefit from medical research future fund. But we believe that anyone who cares about the health of Australians is obliged to resist both the proposed healthcare changes, and the deceptive trick of linking them to the good of medical research.

If health and medical researchers do not stand up now, we will be left not only with a less coherent and less fair health care system, but with the moral blight of having silently colluded in the destruction of universal healthcare. Once destroyed, this will be almost impossible to claw back. We should reject this governments’ urgency rhetoric, lack of compassion for the least well-off, and rejection of solidarity and equity as fundamental Australian values.

Hockey and Abbott should put their rabbit back in their hat. We have not taken our eyes off the real issue: a fair health care system.