Category Archives: policy

health market quality, healthcare, policy, politics

Margaret Faux: Unitended consequences of streamlining Medicare billing

 

http://blogs.crikey.com.au/croakey/2014/12/16/tony-abbott%E2%80%99s-medicare-%E2%80%9Cdeforms%E2%80%9D-or-how-to-trick-senators-101/

Tony Abbott’s Medicare “deforms” or How to Trick Senators 1.01

MARIE MCINERNEY | DEC 16, 2014 3:51PM | | PRINT

The Federal Government’s co-payments Plan B will add another layer of co-payment complexity to the Medicare system that neither doctors nor patients fully understand now. That raises a whole range of issues around unintended consequences, particularly for patients but also for our system, which has prompted this appeal to the Senate to learn from what’s happened in the past and look to different solutions in the future.

***

Margaret Faux writes:

Senators, section 20A needs your help, urgently!

Section 20A of the Health Insurance Act 1973 (the Act) is Medicare’s heartbeat. One of the key machinery provisions of the Act, it describes Medicare’sbulk billing arrangements, and it is fibrillating on the verge of collapse.

Section 20A has been amended, repealed, re-introduced and tinkered with on 16 occasions since it was first introduced. Some of the changes have been incidental but one was not, and it has had long term consequences which have contributed to the continuing upward spiralling of inpatient medical fees. The intention was that it would have the reverse effect.

Tony Abbott’s latest stunt will see the same upward spiralling of GP fees, because when you look beyond the smoke and mirrors of the most recent co-payment iteration, it is nothing more than a cunning manoeuvre to divert attention from the main game. The new proposal cannot be introduced by regulation alone, and it’s the sneaky little legislative change that is required, that will break Medicare’s back. It happened in 2000 and it is happening again.

Bulk billing 1.01

Unlike much of Medicare’s legislative scheme which is mind bogglingly complex, section 20A describes a simple two step bulk billing process (the legal term being an assignment of benefit). My changes in brackets and bolded:

S20A Assignment of Medicare benefit

(1)  Where a medicare benefit is payable to (a patient) …. (the doctor and the patient) may enter into an agreement, in accordance with the approved form, under which:

(a)  (the patient) assigns his or her right to the payment of the medicare benefit to (the doctor); and

(b)  (the doctor) accepts the assignment in full payment of the medical expenses incurred in respect of the professional service by the (patient).

Bulk billing has always been optional by virtue of the inclusion of the word ‘may’ in section 20A, however in choosing to bulk bill, the doctor forgoes his or her right to collect any additional fees from the patient, because he or she must accept the bulk bill amount ‘in full payment’ for the service provided.

Doctors have been found guilty of criminal fraud for breaches of this section in circumstances where they have charged their patients additional fees or ‘co-payments’ when bulk billing, including when the co-payments have been called something else such as booking fees or counselling fees. The current legal position therefore is that irrespective of the name allocated to any ‘co-payment’, it is illegal to charge it when bulk billing for a single professional service. The only exception involves the administration of certain vaccinations, which provision is neatly tucked away in the regulations.

The High Court has upheld this interpretation on numerous occasions and, with the exception of two brief periods in the history of s20A,bulk billing has always operated in this way. Seems pretty straight forward.

Last week in his joint press release with Health Minister Peter Dutton, Prime Minister Tony Abbott announced that under the new proposal an optional co-payment of $5 will be permitted when bulk billing. To enable this, an amendment to s20A of the Act will be required. So what’s the big deal about that?

Well we’ve been down a very similar path before when s20A was amended by the introduction of subsection (2A), which was necessary to facilitate the introduction of no-gap schemes, and unfortunately, it didn’t quite go as planned.

No-gap billing 1.01

No-gap schemes are a sort of hybrid bulk billing system for inpatient services. The fee paid to the doctor has two components; the first is a 75% Medicare rebate, the second is a top up by the private health fund, after which one total amount is paid to the doctor.

When introduced, the stated purpose of these schemes was to limit the out of pocket expenses faced by patients when they go to hospital. The idea was that there would be…well…no-gap, except when there was a gap, called a known-gap, which would be permitted under a sort of sub-branch of the new no-gap schemes.

When these schemes were debated in the House of Representatives on 10 April 2000, MPs variously espoused the complete protection and safeguarding of consumers, expressed concern that there appeared to be insufficient detail as to how patients would be informed about fees, celebrated the fact that medical fees had finally been conquered and patients would thereafter be empoweredto shop around for doctors, and one particularly excited and optimistic MP even suggested that these schemes would somehow help us all to better understand how health insurance operates.

It was only the Member for Lowe John Murphy who was alive to the fact that changing s20A might have unforeseen consequences. He said:

I believe that the amendments made to the Health Insurance Act 1973 to allow automatic assignment of a contributor’s Medicare benefit to a registered organisation to facilitate simplified billing and payment arrangements to be built into the gap cover scheme will mean yet one more way in which bulk-billing will be undermined—something that the Liberal Party has always wished to accomplish. Bulk-billing is something that those who sit on this side of the House will defend to the death.

Bulk billing was indeed undermined but the seemingly innocuous change to s20A was largely over-shadowed by the greater objectives of streamlining and simplifying inpatient billing processes. The necessary change to s20A appeared to be nothing more than a simple mechanical tweaking of the Act to facilitate the operation of the new schemes. And it was true that the schemes could not operate without this tweak. When the go live date came around, the schemes were sold to consumers and health professionals as ‘simplified billing’ arrangements. It’s perhaps the greatest misnomer in the entire Medicare mire.

There are just under 6000 Medicare services, most of which are claimable to each of the 36 registered health funds in Australia, all of whom have no-gap schemes but not known gap schemes, all with unique rules and requirements, some capping their known gap amounts, others not, all with different fee schedules and payment arrangements and some even pay different rates in different states. Only those at the claiming coal face (where the tax payer dollars are spent) really understand just how complex medical claiming is, how easy it is to make unintentional errors and how difficult it is to correct them. No-one knows that in practice, the known gap is usually known to no-one except the patient. And this is not because of any deliberate misuse of the system by anyone, it occurs because the system itself is flawed. And that innocuous little tweak to s20A took the patient right out of the transaction, which in effect created an open book of cheques pre-signed by the patient (though the patient is oblivious to this) just waiting to be cashed.

While doctors do their level best to stay off Medicare’s radar, out of court and comply with the rules, if the rules are labyrinthine and the machinery of billing is left to secretaries, administrators and third parties, then there are bound to be unintentional slip-ups.

In attempts to apply quality control measures to the huge volumes of claims hitting their systems, some health funds are now using data matching processes to try to capture inconsistencies between the hospital claim (this is for the accommodation and theatre fees) and the medical claim. The two claims are supposed to match. But this is also fraught because there is no way of knowing which of the two claims is incorrect when a mismatch is identified. Hospital account departments make errors too. In fact this week a client asked me what she should do because she had become aware that the hospital had claimed incorrectly in her name. She said:

The hospital has sent a hospital accommodation bill to the patient stating that the mirena was inserted for contraceptive reasons but it was actually for another reason for which the relevant MBS item number is different than the one they submitted which was incorrect. When I submit my claim which item number should I use?

Confused and worried doctors are as common as confused patients in the world of medical billing. Patients have often been told one thing by their health fund, another by Medicare, another by the hospital, yet another by the doctor and often we tell them something different again.But spare a thought for doctors, they struggle too. Yesterday, on a fairly typical day in the office, a phone call came through from a brand new surgeon just starting in private practice enquiring about medical billing. I asked him if he had given consideration to the claiming method/s he wanted to use – bulk billing, no-gap, known-gap, full gaps? He replied:

‘Sorry, I don’t know what any of those are; I’m just new to all of this.’

It’s a standard response, no surprises there.

Patients are mostly in the dark when it comes to medical fees and would not know if Medibank Private’s known-gap scheme has a cap or not (it does) and will have no hope of understanding when the proposed $5 co-payments can or can’t be charged, and it will be impossible to protect them from incorrect charges being raised (even if they are raised unintentionally). Consider these real examples of a trip to the GP which were put to me by GPs during a webinar presentation just a few weeks back.

‘What if a patient has a consultation, a mirena inserted, and a wound dressed? Do I have to bulk bill them all or can I split them and charge fees for some and not others? What are the rules?’

‘What about a complex skin cancer removal, a consultation and a vasectomy?’

‘What if the patient comes in and has a consult, is sent off for an x-ray and then comes back later that day with the x-ray results and we find a fracture, but it was caused by a metastasis (cancer invading the bone)?’ – This means that what started off as a suspected simple broken bone has now become a cancer diagnosis and the doctor will likely spend a very long time planning the treatment and management of the patient –‘Is it two item 23s or one item 23 and one item 36 or just bundle it all up into one item 44 or how do we bill for that?’

The rules that apply to each of these scenarios are neither simple nor consistent nor even readily accessible by perusing the Medicare Benefits Schedule. Given doctors are already unsure about how to correctly bill for these services, what hope will patients have? Rumour has it that the Government will try to explain the new scheme by way of an advertising campaign. But so unique is each patient encounter that no national advertising campaign is ever going to make this clear – not for patients, or doctors. It would be a bit like trying to explain the tax system in a 30 second grab on prime time television.

There are two end user groups of the Medicare system, doctors and patients, neither of whom fully understands how it works, and adding another layer of co-payment complexity, facilitated by a seemingly minor change to the legislation, will only serve to compound the difficulties they already grapple with. And just as there were insufficient safeguards to protect consumers when s20A (2A) was inserted to facilitate no-gap schemes, there are not only insufficient safeguards under the Government’s co-payment proposal, there are none.

Instead of shifting responsibility for the health of Medicare to the end users, a responsible government will first look within Medicare for answers. There is known waste, inefficiency and incorrect claiming amounting to over $1 billionper year, that neither increasing the Medicare levy nor introducing co-payments will fix. And if addressing internal inefficiencies to save costs is good enough for the ABC why is it not also good enough for Medicare?

So Senators, your predecessors made what they thought was an innocuous change to s20A for the purposes of simplified billing. Don’t fall for today’s ruse of establishing a ‘price signal’. Do what every responsible householder would do – see if you can make what you have work better for you first, before deciding you will have to pay more for the same service.

Margaret Faux is a lawyer, the founder and managing director of one of the largest medical billing companies in Australia and a registered nurse. She has been involved in Medicare claiming for 30 years and is a research scholar at the University of Technology Sydney examining the interface between Medicare and medical practitioners. 

The illustration is by Bradfield Dumpleton, a freelance illustrator and independent arts educator with a passion for creative communication and who specialises in cartoon art for community health and educational organisations.  For more info: bradfielddumpleton.com

complex adaptive systems, data saving lives, EF, facts & data points, health market quality, healthcare, policy, politics, quantified self, rapid learning health systems

Yach: Changing the Landscape for Prevention and Health Promotion

 

http://www.huffingtonpost.com/dr-derek-yach/changing-the-landscape-fo_1_b_6439328.html

Become a fanExecutive Director of the Vitality Institute

Changing the Landscape for Prevention and Health Promotion

Posted: Updated:

By Bridget B. Kelly and Derek Yach*

Chronic diseases like heart disease, diabetes, and cancer are major contributors to poor health and rising health care costs in the U.S. The cost of treating these conditions is estimated to account for 80 percent of annual health care expenditures. More and more, experts agree on the great potential for preventing or delaying many cases of costly chronic diseases by focusing on environmental, social, and behavioral root influences on health. Yet the U.S. has been slow to complement its considerable spending on biomedical treatments with investments in population-based and non-clinical prevention interventions.

What is getting in the way of strengthening our investments in prevention and health promotion? A few consistent themes emerged across multiple expert consensus studies conducted by the Institute of Medicine (IOM), which were summarized in the report Improving Support for Heath Promotion and Chronic Disease Prevention — developed in support of the recent Vitality Institute Commission on Health Promotion and Prevention of Chronic Disease in Working-Age Americans.

First, prevention is challenging — chronic health problems are complex, and so are the solutions. Second, decision-makers who allocate resources have tough choices to make among many competing pressures and priorities; prevention and promotion can be at a disadvantage because their benefits are delayed. Third, there is a need for better, more usable evidence related to the effectiveness, the implementation at scale, and the economics of prevention interventions. Decision-makers need information that makes it easier to understand, identify, and successfully implement prevention strategies and policies. As noted in a recent opinion piece in the Journal of the American Medical Association (JAMA), limited investment in prevention research has resulted in an inaccurate perception that investing in preventive measures is of limited value. This has profound implications for federal funding allocations.

The mismatch in funding allocations is seen right at the source of our nation’s major investment in new health-related knowledge: the National Institutes of Health (NIH). A new paper in the American Journal of Preventive Medicine found that less than 10 percent of the NIH annual budget for chronic diseases is allocated to improving our knowledge base for effective behavioral interventions to prevent chronic diseases. This means that despite the immense potential for prevention science to reduce the burden of chronic diseases in the U.S., it is woefully underfunded compared to what we invest in researching biomedical treatment interventions for these conditions. NIH investments affect what evidence is ultimately available to those who decide how to allocate resources to improve the health of our nation, and they also affect the kinds of health experts we train as a country. By not investing in prevention science and in a future generation of scientists capable of doing high quality research in prevention, we are perpetually caught in the same vicious cycle where prevention continues to lag behind in our knowledge and therefore our actions.

There is hope that the landscape is slowly changing. Initiatives such as the NIH Office of Disease Prevention‘s Strategic Plan for 2014-2018 and the Affordable Care Act’s mandated Patient-Centered Outcomes Research Institute (PCORI) have the potential to strengthen prevention science and build the evidence-base for effective prevention interventions. Innovations in personalized health technologies and advances in behavioral economics also show great promise in improving health behaviors for chronic disease prevention.

The Vitality Institute Commission’s report emphasized the need for faster and more powerful research and development cycles for prevention interventions through increased federal funding for prevention science as well as the fostering of stronger public-private partnerships. It is essential to generate and communicate evidence in a way that enables decision-makers to understand the value of investing in prevention while taking into account their priorities, interests and constituencies. This will lead us to more balanced investments, make prevention a national priority, and boost the health of the nation.

*The authors are responsible for the content of this article, which does not necessarily represent the views of the Institute of Medicine.

EF, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

A pinch of prevention will prevent a pound of turnstile medicine

 

http://www.afr.com/p/opinion/pinch_of_prevention_will_prevent_cTMfa5vns8VzT46UA8cigJ

JOHN DWYER

A pinch of prevention will prevent a pound of turnstile medicine

PUBLISHED: 12 HOURS 58 MINUTES AGO | UPDATE: 12 HOURS 38 MINUTES AGO

 

A pinch of prevention will prevent a pound of turnstile medicineA lack of infrastructure in Australia to care for more people in a community, rather than a hospital, costs us dearly. Photo: Louie Douvis

JOHN DWYER

Poorly considered and obviously unacceptable policies have forced the government to go back to the drawing board to consider ways to improve the cost effectiveness and sustainability of our health care system. This time let’s move beyond the government’s focus on having us pay more for a visit to our GP to concentrate on the evidence-based structural reforms we should be discussing. This time broad consultations are promised. Hopefully, the following facts and suggestions will influence decisions.

A good start would see the government stop talking about the fiscal sustainability of Medicare. Were it not for the destructive division of health care responsibilities shouldered by State and Federal governments, Canberra would not be looking at Medicare as if were isolated from the rest of the health care system. Hospital expenditure, at nearly $60 billion a year, dwarfs Medicare spending ($19 billion a year) and is increasing more rapidly. The immediate catalyst for changes to Medicare is not a fiscal crisis – our 9.3 per cent of GDP spent on health is about average for the OECD –but rather the unsatisfactory health outcomes delivered that are fuelling the growth in hospital care. A lack of any real infrastructure to provide our community with an improved capacity to prevent illness and care for more people in a community rather than hospital setting is costing us dearly.

More than 600,000 admissions to hospital each year (average cost more than $5000 per episode) could be avoided by a timely community intervention in the three weeks prior to admission. There is no doubt that the future of cost-effective, readily available hospital care is dependent on a reduction in the demand for hospital services. That must be the goal of a restructured Primary Care system. Last year Australians forked out $29 billion to supplement their health care (second only to the US in terms of out of pocket expenses). Much of this was spent on paying for surgery in the private sector. Public hospitals are swamped with complex medical patients seriously reducing their capacity to offer timely surgical services. Reducing medical admissions and restoring timely surgical services is a key to reigning in surgical costs and better educating the next generation of surgeons.

This time could our new health minister and her department open their eyes to international trends in cost effective health care that are producing better health outcomes. There is now an abundance of evidence that a focus on prevention in a personalised health system improves outcomes while slashing costs. Some systems have reduced hospital admissions by 42 per cent over the last decade. The British government has just been presented with a review that concluded that an extra 72 million ($132 million) spent on improving primary care in the community would save the system 1.9 billion ($3.5 billion) by 2020. The data available provides the government with a clear message that it does not want to hear. Only by spending more money on arestructuredMedicare will significant system wide savings be achievable.

A competent government would be looking at a timetable for introducing the highly successful Medical Home model of Primary Care, where teams of health professionals populate a practice and are available to enrolled patients. The infrastructure is available to help people avoid illness, have potential problems recognised earlier, offer co-ordinated in house care for people with chronic problems and care for many in the community currently sent to hospital. International experience tells us that a decade is required for the completion of necessary changes. We need to start on that journey and, fortunately, can do so without any panic about current health expenditure.

There is another related imperative that needs urgent action. Only 13 per cent of young doctors express any interest in becoming a GP. Only 1 per cent are contemplating a career as a rural GP. Primary Care training is rigorous and GPs are true specialists. How does all the rhetoric from Canberra about the pivotal role they play sit with the proposed $31 fee for a standard consultation. The discrepancy in the income potential for GPs when compared to that of other specialists is now huge.

Young doctors looking at the professional life of our GPs are uncomfortable with the current “fee for service” model that encourages turnstile medicine that is so professionally unfulfilling. Many GPs join corporate Primary Care providers preferring a salary. In New Zealand the government has facilitated 85 per cent of the nation’s GPs moving away from fee for service payments. The same is true for 65 per cent of US Primary Care physicians. Throughout the OECD health systems recognising the perverse incentives associated with fee for service remuneration are exploring changes that increase a GP’s remuneration for keeping people well.

There are numerous cost impositions in our health system that should be addressed before we are asked to pay more. Nine departments of health for 23 million people. A $5 billion dollar cost for the private health insurance rebate that could be better spent on achieving the above goals. $20 billion dollars spent on poor value or unnecessary procedures. The government asks: “if you don’t like our ideas then what would you do?” Well, here come the suggestions, please listen.

John Dwyer isEmeritus Professor of Medicine at the University of NSW.

The Australian Financial Review

EF, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems, storytelling

Cth DoH look to disinvestment in low value care

 

http://www.theaustralian.com.au/national-affairs/health/health-eyes-15bn-payoff-from-war-on-waste/story-fn59nokw-1227183948925

Health eyes $15bn payoff from war on waste

EXCLUSIVE – SEAN PARNELL – HEALTH EDITOR

Ten per cent of all health expenditure — as much as $15 billion a year — could be saved through a concerted effort to reduce wasteful programs, marginal treatments and avoidable errors, senior officials in the Department of Health have revealed. The department’s Strategic Policy Group was examining large-scale savings — including an evidence-based campaign of “disinvestment” in low-value programs, drugs and therapies — long before the Abbott government committed to its unpopular GP co-payment.

Documents obtained by The Australian under Freedom of Information laws show the group of deputy secretaries and other officials wanted to reduce spending on low-value interventions and get serious about combating avoidable side-effects, mistakes and infections.

“Members expressed strong interest in holding further discussions on the impact of waste and adverse events,’’ minutes from a November 2013 meeting state. “The discussions could be informed by work already under way in the department on disinvestment and by ongoing work by the Australian Commission for Safety and Quality in Health Care.”

Out of the public eye, the group — which reports directly to the secretary of the department — established an Optimising Value in Health Investment Working Group and talked with Treasury officials. The bureaucrats were keen to redirect money away from areas where there was minimal benefit and potential harm. The FOI documents shed new light on the workings of government and go some way to dispelling the myth that health bureaucrats have not recognised the need to pursue efficiencies and efficacy.

A department spokeswoman yesterday confirmed the work was ongoing. The Grattan Institute has called for more work to be done on the cost of hospital admissions and procedures, noting the cost of a hip replacement in NSW public hospitals varies by more than $16,000. It has estimated savings of $1bn a year from targeting such inefficiencies, as well as $500 million a year from workforce reform — making better use of highly skilled workers — and up to $500m a year through greater use of generic medicines. Some in government believe higher co-payments for drugs and services will make consumers spend less on unproven therapies and, with more of a financial stake in health, be more accepting of limits on access and subsidies.

There are questions about the cost of subsidising new and expensive drugs, especially those with few recipients and limited efficacy, with a Senate committee soon to report on the timing and affordability of access to cancer drugs.

The last federal budget committed to a controversial co-payment that has since been reworked. It also outlined plans to merge the safety and quality commission and five other agencies into a new Health Productivity and Performance Commission — a move that has already halted work on new performance reporting for emergency departments, elective surgery and infections — and replace Medicare Locals with a new primary care structure.

The budget did not take up the commission of audit’s recommendation for a broader, 12-month review of health policies and programs. The government has yet to finalise outstanding reviews into mental health, alcohol and drug services, after-hours GP services, super clinics and unproven natural therapies benefiting from the health insurance rebate. The government believed the health architecture established by Labor needed to be disassembled, price signals put in place for consumers, and growth opportunities given to the private sector before other savings could be pursued. Plans for a reworked $5 copayment — estimated to save $3.5bn by 2017-18 — will start to play out from Monday, when regulations setting new time frames for consultations come into effect.

The government wants GPs to focus on more serious cases, requiring longer consultations, but the Australian Medical Association has warned of $20 co-payments for shorter consultations. About 40,000 people have signed a petition against the copayment and new Health Minister Sussan Ley has yet to start the sales pitch, amid speculation the regulations could be disallowed by the Senate.

complex adaptive systems, EF, healthy habits, policy, politics, storytelling

The Economist: The end of the population pyramid

http://www.economist.com/blogs/graphicdetail/2014/11/daily-chart-10?fsrc=scn/fb/wl/dc/vi/endofpopulationpyramid

Daily chart: The end of the population pyramid | The Economist

Graphic detail
Charts, maps and infographics
Daily chart

The end of the population pyramid

The shape of the world’s demography is changing

THE pyramid is a traditional way of visualising and explaining the age structure of a society. If you draw a chart with each age group represented by a bar, and each bar ranged one above the other—youngest at the bottom, oldest at the top, and with the sexes separated—that is the shape you get. The pyramid was characteristic of human populations since the day organised societies emerged. With lifespans short and mortality rates high, children were always the most numerous group, and old people the least. Now the shape of the global population is changing. Between 1970 and 2015 the dominating influence on the global population was the fertility rate, the number of children a woman would typically bear during her lifetime. It fell dramatically over the period, meaning that the world shifted from having larger to smaller families. The age groups start to become markedly smaller only about the age of 40, so the incline starts much further up the chart than with the pyramid. The shape looks more like the dome of the Capitol building in Washington, DC. Between 2015 and 2060 the biggest influence upon the population will be ageing. Small families are already becoming the norm, the fall in fertility is slowing down and now almost everyone is living longer than their parents—dramatically so in developing countries. So, by 2060, the dome will have come and gone and the shape of the population will look more like a column (or perhaps an old-fashioned beehive).

Read the full article from The World In 2015.

healthy habits, policy, politics

Economist: eat steak and cream

http://www.economist.com/news/books-and-arts/21602984-why-everything-you-heard-about-fat-wrong-case-eating-steak-and-cream?fsrc=scn/fb/te/pe/ed/steakandcream

Healthy eating

The case for eating steak and cream

Why everything you heard about fat is wrong

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?

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.”

From the print edition: Books and arts

data saving lives, EF, entrepreneurship, healthy habits, nutrition, policy, quantified self, rapid learning health systems

Bloomberg: Omada Health Pitch

  • Digital Therapeutics — “Prevent”
  • Digitally-mediated behavioural change
  • Business Model: Charge on success
  • Enterprise Customers

http://www.bloomberg.com/video/take-face-to-face-medicine-to-digital-omada-health-ceo-luSxUqctQcqbjUMc6Wf41g.html

Transcript:

Thanks for joining us on “bottom line.” tell me what your company does.

What is digital therapeutics?

Digital therapeutics is the idea that medicine in the past was conducted in a face-to-face setting.

On the web and social and mobile on the way we can create digital expenses is allowing us to be done digitally.

We take proven lifestyle and behavioral medicine interventions from face-to-face to digital.

That is what we do.

This could help me — well, i don’t smoke, but if i did, it could help me quit and eat healthier, which i don’t do.

Is that the idea — lose weight, quit smoking?

Matt, we can help you with that, and if you want a free pass to our program, let me know . our program helps people with high risk of type two diabetes lose weight and make lifestyle changes over the course of 16 weeks and it is conducted entirely digitally.

I use my iphone or ipad and this will actually work?

Is that the case?

That is the idea.

It can help people proven at risk for type two.

If you help them in a high-tech fashion, our program is digital, a small group environment, where you are paired with others like you and you see how others are doing and we get android and iphone apps and we have a whole bunch of things to make you successful.

Every time i want a delicious cherry coke at lunch, you suggest something that won’t give me diabetes?

The idea is that that moment you want that delicious cherry coke, you think of your health coach and your groups going on with you and maybe you will get a water instead of something better for you.

Very smart man , mark andreessen, is a big backer of you guys.

What is the future of this company?

What does he see there as far as growth is concerned?

You know, i think the interesting bit is what is happening from the company landscape is that you get folks like me with tech and health care backgrounds will bring companies.

I studied neuroscience and i worked at google for a well and went to harvard medical school.

My passion has always been tech plus health care.

I think andreessen horowitz saw a consumer grade, rich product and experience, but to an enterprise customer set with a unique business well behind it that got them excited and that is what led them to pull the trigger on the deal.

$23 million?

What’s next?

Next for us is working with customers.

We have an innovative business model and that we only charge our employer and health plan customers if we are successful with members . because of that model, we have had a lot of demand coming in and it is just scale, scale, scale.

You sold me with harvard med school and you are a neuroscientist with an nba paper you have competition out there — but you’d have competition out there.

What are the barriers?

We do have competition.

The biggest barrier is for entrepreneurs and companies like myself is figuring out health care.

It is incredibly complex.

But so far, so good.

We want competition.

This is a space where there is a lot of people at me.

One third of the adult population has prediabetes, the latest stats from the cdc.

Let’s have a lot of people take a bite.

I wonder about results.

How can you prove that your programs give people the results they want in order to pay money up front and center for your courses — sign up for your courses?

The first is in the world of behavioral medicine.

There are a lot of published studies that show you what you need to achieve from the results standpoint, and then because of the element in our program like the digital scale, the cell phone chip, we can determine if people are successful and show the results in a very transparent and authentic way to our enterprise partners.

Diabetes is obviously a huge and growing problem.

I am certainly at risk for it.

But the weight loss thing is where i guess you will make the big money.

Type 2 diabetes is correlated to being overweight but it is not the only thing good genetics comes into play as well.

As a country, if we are to avoid the stats the cdc put out, 40% of adults of finding out at some point in their life that they are thank you, there needs to be weight loss and lifestyle intervention programs.

I’m just saying that if your marketing materials show that i lost 10 pounds in weeks with this outcome everyone will sign up.

It’s fascinating, what happens when we work with a self-interested employer is that employees who go through a program and become successful rave about it and tell their colleagues and they get colleagues to sign up.

Thanks very much.

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

HBR: What the Insurance Industry Can Do to Fix Health Care

PHI driven implementation of value based health care…

https://hbr.org/2014/12/what-the-health-insurance-industry-can-do-to-fix-health-care

What the Insurance Industry Can Do to Fix Health Care

DECEMBER 23, 2014

Health insurance companies are uniquely positioned to save the day in our ailing health system. Yes, you heard me correctly: health insurers.

Health insurers — or “payers” — are reviled nearly universally. Confused by “explanation of benefits” forms and denials of coverage and frustrated by rising deductibles, co-pays, and costs of care, consumers rank their experiences with health insurers below those with cable companies and internet service providers. Physicians and other care providers — who are constantly negotiating price of services and filling out piles of paperwork — don’t like payers much either.

All this makes insurers unlikely heroes. But we need someone to cut through the complexity of the current system, demand true value from providers, and create better options for consumers. Insurers increasingly look like the folks who can do the job and reinvent their business at the same time.

How? They can use their market power (they direct the bulk of health care dollars) and understanding of different consumer segments to create innovative products, services, and partnerships that address consumers’ needs. In the process, they can help move us all toward a low-cost, value-based health care system. Here are some specific ideas on what payers could do:

Act as true partners to value-based providers. Most payers today are piloting new economic models that pay providers not for the services they provide but for the value they create. Most, however, are neglecting a key opportunity: helping providers change their operating model. To succeed in value-based care, providers need data, analytics, smart clinical-care teams, and managerial support. Insurers are well-positioned to provide all this. They can also help providers become more efficient and assist them in navigating the tricky financial transition from fee-for-service to fee-for-value economics. Most important, insurers can help the very best provider organizations succeed by using them as the core of attractive, competitively priced insurance products.

Offer options for low-cost, convenient care. One area of waste in health care is the use of physician offices and hospital emergency departments to treat minor conditions such as sore throats, urinary infections, and allergies. Payers can make it easy for their members to get care 24/7 in more appropriate settings by partnering with retail, urgent care clinics, and telehealth providers. They can also offer the data connectivity needed to keep the consumer’s primary care provider in the loop. Oscar, the New York health insurance company launched last year, received fanfare in the press over its sleek offering, which includes unlimited phone and video calls with physicians and a “doctor on call” service that provides prescriptions by phone or e-visits. A number of retail pharmacy chains are also actively pursuing retail health and wellness clinics in stores to boost growth.  Walmart has been piloting low-cost care clinics offering a $40 office visit that could dramatically reset the cost bar if scaled broadly.

Cover new wellness- and prevention-oriented treatments. Such options can serve as effective adjuncts to traditional benefits and encourage the trend toward more self-care. Aetna, for example, has offered mindfulness and yoga training to 6,000 of its employees. Its research shows that lower employee stress improved productivity by 69 minutes per week and gave an 11:1 return on investment. Similarly, articles in The New York Times, TIME, Scientific American, JAMA, and The Huffington Post cite growing evidence of the efficacy of meditation programs.

Explode the PPO model. Today the gold standard for health insurance is a preferred provider organization, a huge collection of doctors assembled to provide something for everyone but no special benefit to anyone. Insurers can do a better job for consumers and create real value by developing hassle-free mass customization. In this new model, consumers can choose from lifestyle-based curated options that offer trade-offs across risk level, health-savings options, primary-care models, alternative networks, network breadth, coaching and navigation programs, rewards programs, contract length, and incentive structures. Transparency tools and crowd-sourced reviews will spotlight value and multi-modal coordinated care delivery (think care teams that seamlessly work with telehealth providers, health coaches, and retail clinics) will help cut costs considerably. Consumers will be able to trade their own health engagement into benefit dollars and rewards that they can use seamlessly. While true à la carte insurance customization is not yet a reality, private exchange platforms are starting to provide a stepping stone to get there. For example, Maxwell Health, a new private exchange platform, presents a beautiful interface with lifestyle-focused packages that make product selection simple and tailored for you.

Sell convenience and personalized service. Most health care could hardly be less convenient. Now that consumers have unprecedented purchasing power (rise of public and private exchanges) and bear unprecedented costs (mounting high deductibles and premiums), they expect iPhone-like service. There is tremendous opportunity for payers to make the health care experience simpler and more supportive with online appointment scheduling, clear data and reviews, personalized suggestions, navigation apps with predictive decision support, reward programs, peer-to-peer support, and many other tools. Making the consumer experience better is smart for payers too. They can build stickier consumer relationships and generate new opportunities to address consumers’ growing health and lifestyle needs.

Power healthy behavior change. Some 50% of the determinants of health are driven by lifestyle and personal behaviors. Changing people’s behavior is a tall order but is necessary to improve health care. There are already examples of innovators that are succeeding, such as Omada Health with weight loss for pre-diabetics and Zipongo with healthy eating. We’ve only begun to deploy behavioral science, advanced wearable/monitoring technologies, and machine learning to understand the behaviors and motivations of different groups to predict and prevent acute events and connect people with the solutions that work best for them.

Serve as the bridge between new tools and consumers. In the first half of 2014,venture capital investment in digital health grew by 176%, spawning new consumer-centric companies with interesting approaches to consumer health. But there’s a chasm between these unscaled point solutions and the consumers who could use them. Payers can bridge the gap, using Amazon-style analytics and personalization to better understand consumer types and then connect them at the right place and time to the best-suited offerings. Better yet, payers don’t need to build the bridge themselves: A growing set of powerful consumer-engagement platforms (e.g., WellTok and Optum’s Rally) are moving along this path.

Payers have economic incentives to do everything I’ve described. The Affordable Care Act puts limits on the margins they can earn from their traditional business (Oliver Wyman estimates payer margins may shrink by a third), and an evolving marketplace means that they will face significantly more competition — from each other, health care providers, and new entrants that see an opportunity to capture growth in a $3 trillion market. The options I’ve described would let payers move into non-regulated markets and potentially generate revenue from discretionary consumer spending — a growing pot of money they have not accessed much.

Can they win consumers over? One advantage of being in an industry people don’t like is that there are many opportunities to pleasantly surprise the consumer. The good news is that the things that will make consumers happy — more convenience, customization, support for doctors, coordination of care — can all contribute to attractive new business opportunities while making the health care system more efficient, effective, humane, and sustainable.

Sukanya Soderland is a partner in Oliver Wyman’s Health and Life Sciences practice and a leader in the firm’s Health Innovation Center.

 

data saving lives, EF, health market quality, healthcare, policy, politics, rapid learning health systems

How Medical Care Is Being Corrupted

 

 

http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.html?_r=0

 

How Medical Care Is Being Corrupted

By PAMELA HARTZBAND and JEROME GROOPMAN 

Alex Merto

WHEN we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.

But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.

Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.

For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.

Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.

These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.

It is not just treatment targets but also the particular medications to be used that are now often dictated by insurers. Commonly this is done by assigning a larger co-payment to certain drugs, a negative incentive for patients to choose higher-cost medications. But now some insurers are offering a positive financial incentive directly to physicians to use specific medications. For example, WellPoint, one of the largest private payers for health care, recently outlined designated treatment pathways for cancer and announced that it would pay physicians an incentive of $350 per month per patient treated on the designated pathway.

This has raised concern in the oncology community because there is considerable debate among experts about what is optimal. Dr. Margaret A. Tempero of the National Comprehensive Cancer Network observed that every day oncologists saw patients for whom deviation from treatment guidelines made sense: “Will oncologists be reluctant to make these decisions because of an adverse effects on payments?” Further, some health care networks limit the ability of a patient to get a second opinion by going outside the network. The patient is financially penalized with large co-payments or no coverage at all. Additionally, the physician who refers the patient out of network risks censure from the network administration.

When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.

We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.

Medicine has been appropriately criticized for its past paternalism, where doctors imposed their views on the patient. In recent years, however, the balance of power has shifted away from the physician to the patient, in large part because of access to clinical information on the web.

In truth, the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient.

In 2010, Congress passed the Physician Payments Sunshine Act to address potential conflicts of interest by making physician financial ties to pharmaceutical and device companies public on a federal website. We propose a similar public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.

Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interests of their patients.

Pamela Hartzband and Jerome Groopman are physicians on the faculty of Harvard Medical School and co-authors of “Your Medical Mind: How to Decide What is Right for You.”

A version of this op-ed appears in print on November 19, 2014, on page A25 of the New York edition with the headline: How Medical Care Is Being Corrupted. Order Reprints| Today’s Paper|Subscribe