Category Archives: rapid learning health systems

data saving lives, entrepreneurship, healthcare, policy, quantified self, rapid learning health systems

JP Morgan Health Conference wrap

  • It’s a different world today, one where new laws and new digital technologies are upending the way health care is delivered.
  • The Affordable Care Act has led to this shift, and has created a business model that didn’t even really exist five years ago.

http://blogs.wsj.com/venturecapital/2014/01/16/google-ventures-says-jp-morgan-health-conference-changing-with-the-times/

January 16, 2014, 4:39 PM
Google Ventures Says JP Morgan Health Conference Changing With the Times
For more than three decades, the JP Morgan Healthcare Conference in San Francisco has been the almost-exclusive domain of pharmaceutical companies, the place where the Mercks and Pfizers of the world meet biotechnology startups who help them fill their pipelines.

 

But it’s a different world today, one where new laws and new digital technologies are upending the way health care is delivered.

Attendance at the conference has changed to reflect the new reality, as health-insurance companies, software developers, purveyors of big-data analytics and a range of other information technologies have begun to fill out the roster, on the presenters’ stages and in the nearby hotels where the deal-making happens.

“I’ve been coming to this for five years,” said Krishna Yeshwant, a general partner at Google Ventures, which backs a range of health- and health-information startups. “When I started it was all pharma, and all the talk was about disease targets.

“The Affordable Care Act has led to this shift, and has created a business model that didn’t even really exist five years ago. There is all this talk now about analytics, about digital health, health-care delivery. I have [portfolio company CEOs doing information-technology] who ask me, ‘Should I be going to JP Morgan?,’ and I say ‘Yes, you have to be here.’ A few years ago I might have said no.”

This year’s conference not only saw a fireside talk from Acting National Coordinator of Health I.T. Jacob Reider, but presentations from electronic health-record providers like Practice Fusion Inc. and athenahealth Inc.

The conference also featured a standing-room-only panel discussion with startup digital-health companies like medical-information network ShareCare Inc., “digital medicines” company Proteus Digital Health Inc. and big-data analytics company Kyruus Inc., joined by health IT investors Qualcomm Ventures and Thrive Capital. It was the first year digital health had gotten such prominent billing at the conference. JP Morgan organizers declined to comment about trends in conference attendance in recent years.

One provision of federal health reforms ties hospitals’ reimbursement for treatment more closely to patient outcomes than to the volume of patients treated.

Feeling more scrutiny, health-care providers now have an immediate need for the types of software and big-data products that can help them track treatment efficacy and patient progress over large populations of people, Dr. Yeshwant said.

“These kinds of products always made good sense,” he said, “but there was no real financial incentive. Now there is. If you’re not doing this, you’re going to disappear.”

More of a gradual change than an overnight transition, the “outcome-based medicine” provision of health-care reform has drawn a number of new players to the JP Morgan conference, including all of the country’s top health insurance companies and a range of IT providers who want to do business with them and with hospitals, Dr. Yeshwant said.

“Many of these people come because they want to be near the conversation,” he said. “Things are not changing abruptly, but these changes are very big. A lot of people feel the need to be near all of it.”

Google Ventures is backing a number of health information-technology companies, including genomic analysis company Foundation Medicine Inc., big data company DNANexus Inc. and consumer-genetics company 23andMe Inc.

Write to Timothy Hay at timothy.hay@wsj.com.

complex adaptive systems, data saving lives, facts & data points, rapid learning health systems

Flu Predictor

Pretty cool… lots of good imagery for a presentation.

One day, it’ll find itself on the weather report.

Put another way, the weather report is one of the most popular, early uses of big data available in the community.

 

http://www.fastcoexist.com/3025365/find-out-when-youll-be-sick-with-the-first-online-flu-predictor

Find Out When You’ll Be Sick With The First Online Flu Predictor

Want to know when exactly to start avoiding everyone around you who so much as sneezes? This online tool can tell you when the flu will strike in your city–more than two months in advance.

I should have seen it coming. First it felled my boyfriend’s roommates, then my boyfriend, and then my roommate. Then, two weeks into the viral sensation sweeping the nation, I fell asleep with a sore throat, and woke up with a head full of mucus.

Luckily, it wasn’t the flu. But if it was, last week was also the first time I could have predicted when such a flu might strike my part of town, as it does during the peak flu months between October and April. That’s because, earlier this month, scientists at Columbia University’s Mailman School of Public Health uploaded a first-of-its-kind flu prediction model online.

In December, assistant professor of environmental health sciences Jeffrey Shaman told Co.Exist about the tool he and his colleagues had developed to predict the flu up to nine weeks in advance. Using data from Google Flu Trends and weekly CDC infection rates, the Columbia model was able to predict the exact timing of flu arrival accurately in 63% of the American cities it analyzed.

One day, Shaman suggested, the predictions might become so accurate that they’re eventually broadcast next to the weather on TV.

In the meantime, that model now exists on the good ‘ole Internet. It predicts some relief for Lincoln, Nebraska, which appears to be coming down from quite an illness, as does Wichita. Boston, on the other hand, looks like it’ll be experiencing an increase in flu cases over the next couple of weeks, as will New York City.

On the map above the predictor, you can check out CDC data for flu patient visits to the doctor’s office from the week prior. Next to the predictor, click on your state in the tree map to find out which cities will be most afflicted.

[Image: Blowing nose via Flickr user Anna Gutermuth]

complex adaptive systems, cool, data saving lives, entrepreneurship, healthy habits, nutrition, policy, quantified self, rapid learning health systems, startup, storytelling

Fear + Clear Action = Effective Behaviour Change

  • people indulge in unhealthy behaviours to relieve stress and anxiety
  • ads that cause stress and anxiety can drive unhealthy behaviours
  • one solution is to couple compelling threats with clear and specific paths to behaviour change
  • another approach is to apply the adicitive rewards that video games create for real life challenges
  • SUPERBETTERLABS.COM build video games which build resilience and maintain motivation while working to overcome injuries, anxiety and depression

 

http://www.iodine.com/blog/anti-smoking-ads/

Why Graphic Anti-Smoking Ads Make Some People Smoke More Cigarettes

Jessica Goldband

If these images make you squirm or want to click away, you’re not alone.

get-unhooked-man-1anti_smoking130328_anti_smoking_ad_thumb

How, then, can this type of message change the choices you make? Can we really be motivated by something that turns us off, rather than on?

You’d think, perhaps intuitively, that the scarier the ad, the more powerfully it affects our behavior. And the research supports that argument. Indeed, since the classic 1964 Surgeon General report on “Smoking and Health” came out 50 years ago this month, that’s been the basic strategy for health communication around the issue. But there’s a catch. A BIG one.

While we’ve seen a significant drop in global smoking rates (down 25% for men and 42% for women) since those landmark reports in the 1960s demonstrated the link between smoking and lung cancer, many people continue to smoke: 31% of men and 6% of women. In the U.S., 18% of adults (down by half since 1964) continue to do something they know might kill them.

Public health agencies have spent years communicating the dangers of smoking. Their anti-smoking ads have grown increasingly disturbing, threatening us with graphic images of bulging tumors and holes in our throats — possibly to try to reach that last stubborn segment of the population that hasn’t kicked the habit.

Why aren’t these ads working?

Turns out, the most recent and comprehensive research on so-called “fear appeals” and attitude change says that this kind of messaging does work, but only if the person watching the ad is confident that they are capable of making a change, such as quitting smoking. Public health gurus call this confidence in one’s ability to make a change “self-efficacy” — and threats only seem to work when efficacy is high. (The reverse is also true.)

If someone lacks efficacy, ads with fear appeals don’t help. In fact, they make the behaviorworse. How? Many people engage in unhealthy behavior because it makes them feel better and relieves their anxiety.

If you threaten someone who has little to no confidence they can change their behavior, their anxiety goes through the roof. What do they do? Perhaps turn off the threatening ad, walk away, and light up a cigarette — the very behavior you were trying to prevent. This same principle applies to other coping behaviors, such as eating unhealthy types of food or just too much of it.

Unfortunately, anxiety is quite common in this country. According to arecent Atlantic article, 1 in 4 Americans is likely to suffer from anxiety at some point in life. Making big life changes is tough, and it seems as though fear and anxiety don’t energize people, they just paralyze them.

So what’s the solution?

A step in the right direction would be for ad campaigns to couple compelling threats with equally clear and specific paths to behavior change. Or why not apply the rewards built into reaching a new level in addictive video games to apps that people can use for real-life challenges? One great example of this is Superbetter, a social online game to help people build resilience and stay motivated while working to overcome injuries, anxiety, and depression.

Stand-alone threats implicitly assume that people don’t already know how bad their choices are, and can drive them to the very behaviors they wish they could change. Truly effective ad campaigns might still appeal to our fears, but they should also let us wash it all down with a confidence chaser that empowers the more anxious among us to act on our fears.

complex adaptive systems, data saving lives, healthcare, healthy habits, management and leadership, nutrition, policy, rapid learning health systems

Health Care Value

There’s a lot of good buried in this post, but it’s all starting to sounds like the development of a perfect map… not that inspiring.

The data is already there. At a national level, it can be used to inform a national increase in health funding… functioning like a CPI.

——-

Michael Porter defines value as “health outcomes achieved per dollar spent.” … An efficient business gets the most output possible, given current technology, from every dollar spent.

Porter and colleagues adapt microeconomics to health care through their definition of output: patient-centered health outcomes. These are results that individual patients desire: survival, speedy and uncomplicated recovery, and maintenance of well-being over the long term. These are also things that clinicians, payers, and purchasers should seek for their patients, employees, and customers.

The value movement’s definition of outcomes treats the patient as a whole person, insists that measures of outcome transcend disease-specific indicators to account for all of the patient’s conditions, and include data collected over time and space to produce comprehensive measures of patient well-being. Value proponents further insist that inputs be measured comprehensively to include all the costs of producing desired outcomes.

Widely adopted, the concept of value would provide a north star toward which health care providers could navigate.  Its emphasis on the whole patient and comprehensively measured costs would encourage teamwork among clinicians and coordination of care across specialties, clinical units, and health care organizations. The focus on patient-centered outcomes would support increased effort to measure patient-reported outcomes of care, such as their level of function and perceived health status over time.

[…] the lack of data systems to support outcome measurement.  Producing the holistic assessments needed requires the aggregation over time and space of data from multiple clinicians and health care organizations, as well as patients themselves. The health care system’s electronic data systems are just now entering the modern age.

To turn the promise of value measurement into the reality of better care at lower cost, a few short-term actions seem prudent. First, the nation needs a plan to turn the concept of value into practical indicators. Since government, the private sector, consumers and voters all have a vital stake in health system improvement, they should all participate in a process of perfecting and implementing value measures, preferably under the leadership of a respected, disinterested institution. The Institute of Medicine comes to mind, but others could be imagined.  This process should produce an evolving set of measures that will be imperfect initially but improve over time.

Second, both government and the private sector need to invest in the science and electronic data systems that support value measurement. Investments in systems should focus on speeding the refinement of standards for defining and transporting critical data elements that must be shared by patients, providers, and insurers to create patient-centered outcome measures.

 

 

http://blogs.hbr.org/2013/09/getting-real-about-health-care-value/

via

http://www.commonwealthfund.org/Blog/2013/Sep/Should-Value-Be-the-New-Mantra-in-Health-Care.aspx?omnicid=20

Getting Real About Health Care Value

by David Blumenthal and Kristof Stremikis  |   12:15 PM September 17, 2013

Words can spearhead social transformation.  Let’s hope that’s true for “value” in health care. Where other mantras – such as quality or managed care – have failed to galvanize the system’s diverse stakeholders, value may have a chance.

What seems special about the term is that, seemingly simple, it is actually complex and subtle. Under its umbrella, a wide range of interested parties can find the things they hold most dear, from improved patient outcomes to coordination of care to efficiency to patient-centeredness. And it is intuitively appealing. As Thomas Lee noted in the New England Journal of Medicine, “no one can oppose this goal and expect long-term success.”

The question, of course, is whether the term will help spur the fundamental changes that our health care sector so desperately needs. In this regard, a closer examination of the value concept confirms its appeal but also exposes the daunting challenges facing health system reformers.

Michael Porter has defined value as “health outcomes achieved per dollar spent.” Any survivor of introductory microeconomics will hear echoes in this phrase of one basic measure of economic efficiency: output per unit of input. An efficient business gets the most output possible, given current technology, from every dollar spent.

Porter and colleagues adapt microeconomics to health care through their definition of output: patient-centered health outcomes. These are results that individual patients desire: survival, speedy and uncomplicated recovery, and maintenance of well-being over the long term. These are also things that clinicians, payers, and purchasers should seek for their patients, employees, and customers. The value movement’s definition of outcomes treats the patient as a whole person, insists that measures of outcome transcend disease-specific indicators to account for all of the patient’s conditions, and include data collected over time and space to produce comprehensive measures of patient well-being. Value proponents further insist that inputs be measured comprehensively to include all the costs of producing desired outcomes.

Widely adopted, the concept of value would provide a north star toward which health care providers could navigate.  Its emphasis on the whole patient and comprehensively measured costs would encourage teamwork among clinicians and coordination of care across specialties, clinical units, and health care organizations. The focus on patient-centered outcomes would support increased effort to measure patient-reported outcomes of care, such as their level of function and perceived health status over time.

Promising as it is, the emphasis on value also raises illuminating and challenging questions. The first is: why all the fuss with defining it? In most markets consumers define value by purchasing and using things. In the 1990s, personal computers had considerable value. We know that because consumers bought lots of them. Now, with the arrival of tablets, personal computers seem to be losing value.  And so it goes for untold numbers of goods and services in our market-oriented economy. Eminent professors don’t wrack their brains defining the intrinsic value of electric shavers, overcoats, or roast beef.

We need to define the value of health care, however, for a simple but profound reason explained in 1963 by Nobel-prize-winning economist Kenneth Arrow. Arrow showed that health care markets don’t work as others do, because consumers lack the information to make good purchasing decisions. Health care is simply too complex for most people to understand. And health care decisions can be enormously consequential, with irreversible effects that make them qualitatively different from bad purchases in other markets. Americans are therefore reluctant to let the principle of caveat emptor prevail. One reason to define value carefully and systematically is to enable consumers to understand what they are getting, an essential condition for functioning health care markets.

The compelling need for a good definition of health care value highlights another fundamental challenge. We have not yet developed scientifically sound or accepted approaches to defining or measuring either patient-centered outcomes of care, or – surprisingly – the costs of producing those outcomes. The scientific hurdles to defining patient-centered outcomes are numerous. Outcomes can be subtle and multidimensional, involving not only physiological and functional results, but also patients’ perceptions and valuations of their care and health status.  The ability of health care organizations to measure costs is primitive at best and doesn’t meet the standards used in many other advanced industries. Equally challenging is the lack of data systems to support outcome measurement.  Producing the holistic assessments needed requires the aggregation over time and space of data from multiple clinicians and health care organizations, as well as patients themselves. The health care system’s electronic data systems are just now entering the modern age.

Given the value of measuring value, and the current obstacles to doing so, still another urgent question arises: what should we do now? Despite recent moderation in health care costs, our health care system is burning through the nation’s cash at an extraordinary rate and producing results that, by almost every currently available measure, are disappointing.

To turn the promise of value measurement into the reality of better care at lower cost, a few short-term actions seem prudent. First, the nation needs a plan to turn the concept of value into practical indicators. Since government, the private sector, consumers and voters all have a vital stake in health system improvement, they should all participate in a process of perfecting and implementing value measures, preferably under the leadership of a respected, disinterested institution. The Institute of Medicine comes to mind, but others could be imagined.  This process should produce an evolving set of measures that will be imperfect initially but improve over time.

Second, both government and the private sector need to invest in the science and electronic data systems that support value measurement. Investments in systems should focus on speeding the refinement of standards for defining and transporting critical data elements that must be shared by patients, providers, and insurers to create patient-centered outcome measures.

Third, in consultation with consumers and providers, governments need to develop privacy and security policies that will assure consumers that their health care data will be protected when shared for the purpose of value measurement.

Last, and perhaps most important, the trend toward paying providers on the basis of the best available value measurements needs to continue. These payment policies motivate providers to use value measures to their fullest extent for the purpose of improving processes of care and meeting patients’ needs and expectation.

To some observers putting value at the forefront of health care reform may seem obvious and non-controversial.  As Lee notes, who can be against it?  To use an American cliché, it seems a little like motherhood and apple pie: comfortable and widely endorsed. But the value movement could be much more than that.  When value does become a well-accepted principle, we’ll be much closer to making health care better for everyone.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

data saving lives, entrepreneurship, healthcare, rapid learning health systems, startup, technology

VCs investing in US Healthcare

  • US investment in health care was triggered by the affordable care act
  • health is a bigger sector than tech
  • investing in a health insurance start-up presents an interesting strategic level

http://techcrunch.com/2014/01/15/vcs-investing-to-heal-u-s-healthcare/

VCs Investing To Heal U.S. Healthcare

Posted  by  (@jshieber)
The U.S. healthcare system is sick, but increasingly early stage investors are spending money on new technology companies they believe can help provide a cure.

Earlier this week, Greylock Partners, one of the investors behind Facebook and LinkedIn, and the Russian billionaire technology investor Yuri Milner put together a $1.2 million round alongside a group of co-investors to back First Opinion – a consumer facing service selling a way to text message doctors anytime of day or night.

Greylock and Milner join a growing roster of technology investors focused on healthcare in recent years. The number of companies raising money from investors for the first or second time has skyrocketed since the passage of the Affordable Care Act, according to data from CrunchBase.

In 2010, the year in which President Obama signed the ACA into law, there were only 17 seed- and Series A-stage healthcare-focused software and application development companies which had raised money from investors. By the end of last year, that number jumped to 89 companies tackling problems specifically related to the healthcare industry, according to CrunchBase metrics.

Across all categories, investors spent over $1.9 billion in 195 deals with commitments over $2 million, according to a report from early stage investment firm Rock Health. Funding was up 39% from 2012 and 119% from 2011, the Rock Health report said.

And there’s plenty of room for the market to grow, according to HealthSoftwareAppsEarlyFunding0913Google Ventures’ general partner Dr. Krishna Yeshwant. “We’re still at the very beginning of what this is going to look like,” said Dr. Yeshwant.

Google Ventures is addressing the nation’s healthcare dilemma with investments in companies like the physicians’ office and network One Medical Group, which raised a later stage $30 million last March. At the opposite end of the spectrum in December 2013 Google invested in the $3 million seed financing of Doctor on Demand, which sells a service enabling users to video chat with doctors.

Unsurprisingly, the explosion in healthcare investments tracks directly back to the passage of the Affordable Care Act, investors said. “The incentives brought forward by the ACA shift what makes sense,” in healthcare, Dr. Yeshwant said.

“At the highest level there’s now a forcing function to take advantage of the efficiency technology provides,” said Bill Ericson, a general partner with Mohr Davidow Ventures, who led the firm’s investment in HealthTap, a service for consumers to message doctors with healthcare questions.

Overwhelmingly, Silicon Valley is leading the charge in these innovations, according to CrunchBase.

HealthSoftwareAppsTotalFunding0913
This flood of capital has pushed some investors like Founders Fund to re-think their strategy, and de-emphasize healthcare software in search of other, larger opportunities.

““The reason we have somewhat shifted focus away from healthcare IT is because there is so much investment going into that space.  So we think the problems there are being sufficiently addressed by the full market.” said Brian Singerman, a partner at Founders Fund.

The firm’s most recent investment was in Oscar, a new, New York-based insurance company. Yes… an insurance company.

“In healthcare there is a tech stack around genomics, digitization, biometrics, analytics, and actual cures; one of the things that ties that all together is insurance,” said Singerman.

“Launching a new insurance company is not something that happens very often. While you could launch a new insurance company without the Affordable Care Act, the catalyst it gives you by being on the same page as the big incumbents is unprecedented.”
At Google Ventures, Dr. Yeshwant thinks there will be more opportunities for tech-enabled companies like Oscar and One Medical to compete in these broad industrial categories rather than offering point solutions. “Instead of being a piece of the system, it’s being the entire entity,” he said.
“The thing to keep in mind… with the healthcare industry is that it is far bigger than tech. As an entity it is where we’re spending 17% to 18% of GDP, so any one segment is tens of billions of dollars,” Dr. Yeshwant said. “Increasingly you’re seeing IT investors who have a fine sense of disruptive opportunities enter the market.”
Photo via Flickr user BrickDisplayCase
data saving lives, entrepreneurship, healthy habits, musings, policy, quantified self, rapid learning health systems, technology

Location-based prevention services

OK, so here’s the idea:

Our physical environment is loaded with cues capable of triggering healthy and unhealthy behaviours…

  • walk past any take-away, and you might succumb to the call of a chicko-roll (or bottle of water)
  • approach the supermarket, and you might feel the urge to purchase a tub of ice cream (or bag of oranges)
  • do you take the escalator (or the stairs)

Rather than leaving it to fate, why not use a location-triggered message to steer away from temptation, and towards a healthy future.

The danger areas can be configured individually, crowd-sourced or pre-loaded, as can the messages.

complex adaptive systems, healthcare, healthy habits, musings, nutrition, policy, politics, rapid learning health systems, storytelling

Katz smashes it again… it’s the culture, stupid.

“Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm.”

…but how do we operationalise culture change…. it is massive task, but it needs to happen. Purpose perhaps?

http://www.linkedin.com/today/post/article/20140121144506-23027997-obesity-and-oblivion-or-what-i-ve-learned-under-general-anesthesia

Director, Yale University Prevention Research Center

Obesity and Oblivion- or- What I’ve Learned Under General Anesthesia

David L. Katz, MD, MPH

January 21, 2014  

I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.

I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian– privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.

This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.

And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74 birthday last summer with a hilly, 56-mile bike ride.

By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and productivity. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.

Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.

Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness; oblivion.

And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.

True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.

And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words- as nobody ever does under general anesthesia.

Our society’s tendency to “over-medicalize” has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after – wait for it- 17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.

It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.

With that in mind, I ask my fellow parents reading this column; I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.

Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 lbs, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.

Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.

The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.

Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.

It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves- and perhaps thereby perceive a new world of opportunity.

-fin

Dr. Katz was recently named one of the most influential people in Health and Fitness (#13) byGreatist.com. His new book, DISEASE PROOF, is available in bookstores nationwide and at:

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253
http://twitter.com/DrDavidKatz
http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

data saving lives, facts & data points, healthcare, nutrition, policy, quantified self, rapid learning health systems, research methodology

Institute for Health Metrics and Evaluation (IHME)

Gates Foundation backed Washington University team doing some amazing work on gathering, analysing and presenting global burden of disease metrics for easy browsing.

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

Data Visualizations

IHME strives to make its data freely and easily accessible and to provide innovative ways to visualize complex topics. Our data visualizations allow you to see patterns and follow trends that are not readily apparent in the numbers themselves. Here you can watch how trends in mortality change over time, choose countries to compare progress in a variety of health areas, or see how countries compare against each other on a global map.

Not sure which visualization will provide you with the results you are looking for? Click here for a guide that will help you determine which tool will best address your data needs.

GBD Compare is new to IHME’s lineup of visualizations and has countless options for exploring health data. To help you navigate this new tool, we have a video tutorial that will orient you to its controls and show you how to interact with the data. You can also watch the video of IHME Director Christopher Murray presenting the tools for the first time at the public launch on March 5, 2013.

Tobacco Burden Visualization

This interactive data visualization tool shows modeled trends in tobacco use and estimated cigarette consumption worldwide and by country for the years 1980 to 2012. Data were derived from nationally representative sources that measured tobacco use and reports on manufactured and nonmanufactured tobacco.

US Health Map

With this interactive map, you can explore health trends in the United States at the county level for both sexes in: life expectancy between 1985 and 2010, hypertension in 2001 and 2009, obesity from 2001 to 2011, and physical activity from 2001 to 2011.

GBD Compare

Analyze the world’s health levels and trends in one interactive tool. Use treemaps, maps, and other charts to compare causes within a country, compare countries with regions or the world, and explore patterns and trends by country, age, and gender. Drill from a global view into specific details. Watch how disease patterns have changed over time. See which causes of death and disability are having more impact and which are waning.

Mortality Visualization

How does input data become a GBD estimate? Walk through the estimation process for mortality trends for children and adults for 187 countries. See the source data and then watch as various stages in the estimation process reveal the final mortality estimates from 1970 to 1990.

COD Visualization

Where do we have the best data on the different health conditions? For any age group, see where the various data sources have placed the trends in causes of death over time. You can examine more than 200 causes in both adjusted and pre-adjusted numbers, rates, and percentages for 187 countries.

GBD Insight

What are the health challenges and successes in countries around the world?

GBD Heatmap

How do different health challenges rank across regions?

GBD Arrow Diagram

How has the burden of different diseases, injuries, and risk factors moved up or down over time?

GBD Uncertainty Visualization

Where do we have the best data on the different health conditions?

GBD Cause Patterns

What diseases and injuries cause the most death and disability globally?

 

healthcare, policy, rapid learning health systems

Commonwealth Fund 2013 Annual Report

Blumenthal is a top shelf operator and its terrific to see him leading the Fund on new work which includes constructive disruption of the US health system. His opening lines carry a finely crafted, powerful and persuasive message:

“Like every American, like every person on this globe, I treasure the access I have to health care. I know I’m privileged, but every time my family members or I are sick, we are taking risks, that we are entering a system that doesn’t function as well as it should. As a primary care provider, as a scholar, as a professor, I’ve been interested in the same things the Commonwealth Fund is interested in. A high performing health system and vulnerable populations.

We have a system that’s excessively costly, inadequate in quality. Poor results with many other countries on quality metrics. We spend far too much on health care – $2.7 trillion when no other country comes close to that.

It’s important that the most vulnerable access care, because in some ways, they are the canary in the mine. Their vulnerability highlights a general vulnerability.

The Commonwealth fund is dedicated to producing the right information at the right time to make decisions better and make our health care system better.

A high performing health system will be a health system in which the providers of care, the clinicians, doctors and nurses, enjoy their work. It matters to me not just as a policy maker, and a scholar, but as a father, as both my children are physicians in training, and I hope we can leave them a system they can truly enjoy working in.

[….]

The last area, and somewhat new, is what we’re calling breakthrough innovations, which are opportunities to fundamentally transform the system through innovative approaches to health care delivery”

 

http://www.commonwealthfund.org/Annual-Reports/2013-Annual-Report.aspx?omnicid=20

data saving lives, entrepreneurship, healthcare, healthy habits, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology

HICCUP: Health Initiative Coordinating Council

This manifesto aligns tightly with my own vision of how preventive health funding should be financed – data-driven and in a for-profit context.

HICCup

 

The HICCup experiment: Manifesto

Just imagine:

It’s 2019 and the mayor is having a bad day.  She wants to spearhead a new community program for bike-sharing, but she’s not sure the town can afford it.  Meanwhile, one of the new council members is pushing for an overhaul of the school lunch program.  She sighs as the assistant deputy mayor walks in.  “What now, Henry?” she asks with a slight edge in her voice.  But Henry is cheerful: “Mayor, I think we may have a way to fix this. I was just reading about the HICCup Experiment in a town just like ours…. It seems that if we did both the bike program and the school lunches, and made some other changes..”

“But what about our rising health care costs?” asks the mayor.

“That’s the point,” says Henry.  “HICCup showed that we can actually reduce those costs if we do multiple interventions simultaneously…even though none of them by itself would make a difference. And there’s an investment banker who just called us that’s eager to work with us to finance the project.  They’re asking us to set up a meeting with the big employers and Mercy Saints Health. Using the HICCup data, they think they can finance it all out of the health-care cost savings that would result, as long as we commit to following certain protocols.”

And the vision:

Now it’s 2040.  The mayor’s teen-aged son, also called Henry, is discussing his history project on the HICCup Experiment with other members of his MOOC.  “Of course,” he concludes, “the HICCup Experiment proved that multiple interventions can dramatically include the overall health of a community.  But the Experiment itself wouldn’t work anymore, as a funding vehicle.”

“Why not?” asks Susan, who clearly hasn’t done her homework.

Henry responds patiently with the obvious answer: “Because there are very few places with inflated, unnecessary health care costs anymore.”

The background

It is hard to find anyone in health care who does not believe that spending an extra $100 now on healthy behavior – exercise and proper nutrition, counseling for pre-diabetics, risk monitoring, and so on – could yield more than $120 in lowered costs and improved outcomes later. The numbers are fuzzy, of course, and there are plenty of methodological caveats, but there is little dispute about the plausibility and desirability of such an approach.

Yet neither individuals nor communities seem to act on the basis of this knowledge. Moreover, it’s likely that spending $110 now has no impact, as other factors dissipate any gain, but spending $110 million now (vs. a health-care budget of $100 million) should indeed return savings of $20 million annually over time.  Individuals often lack willpower or access to healthy food or convenient exercise facilities, and are surrounded by poor examples that encourage instant gratification rather than effort and restraint. And, on a broader, institutional scale, the money spent and the money to be gained do not belong to the same pocket.

Enter HICCup!

The goal of HICCup, the Health Initiative* Coordinating Council, is to facilitate the launch of five to eight community-wide experiments dedicated to proving that this can work, and to learning from both successful and unsuccessful efforts.  HICCup is a self-appointed counseling service and will persuade and guide local institutions to embrace a long-term perspective and launch a full-scale intervention experiment in their communities. For practical reasons, there are a few guidelines – but anyone who wants to do this without following our rules is welcome to do so.   (*Yes, it used to be “health intervention…” but initiative is more friendly and positive, and still let us keep the logo!)

For starters, HICCup will focus on communities of 100,000 people or fewer. The majority of each community and its institutions must be enthusiastic for the initiative to gain traction. If the community members mostly work for just a few employers and obtain health care from just a few providers, that makes the effort of corralling the players easier. And, of course, you need community leaders – mayor, city council, and others – who will work together rather than undermine one another.

So, how will this be funded? Not by HICCup, which is only a coordinating body.  The trick is for an investor in each community to capture some of what is being spent already on health care. As a rough calculation, assume $10,000 in annual per capita health-care costs, or $1 billion per year in a community of 100,000. (There are also all the separate costs of bad health, which are much harder to count or capture.)  That money ultimately comes from individuals and employers who pay it in taxes, insurance premiums or direct payments; the place to intercept it is somewhere between the payers and the health-care delivery system.

Instead of spending $1 billion a year, imagine spending $1.1 billion the first two years, but, say, only $900 million in the fifth year (possibly a $300 million savings off projected costs of $1.2 billion by then). That sounds like an attractive proposition – but only if someone else will make that initial investment in return for a claim to those presumed later savings.  These numbers are just for illustration; figuring out actual and predicted numbers for each community will be a key task.

The first challenge is for each HICCup community to get the involvement of a benevolent but ultimately profit-driven billionaire or hedge fund, or a philanthropic fund that sees a way to do good while earning money for future goodness. There are a lot of billionaires out there, some with vision. There are health-care companies that might bite, hedge funds looking for large-scale projects, and so-called social-impact bonds. There also are large employers that might decide to work with other employers in certain communities.

The funder makes a deal with whoever is responsible for the health-care costs (buyers): The funder makes upfront investment in health interventions and pays the health-care costs, against continued payment from the health-care buyers of the $1-billion yearly baseline, with the funder to keep (most of) the savings against originally predicted rising costs in later years. The money may be paid by employers, private insurers (which collect it from individuals, who, in the United States, are now required to buy insurance) or from government health-care funds, which will be the trickiest source.

One way or another, the investor/experiment manager will need to figure out how to realign some of the sick-care facilities and workers to some other role, including prevention, serving outsiders or some other use entirely.  That’s the second challenge HICCup experimenters need to address – one that is being addressed in part by the creation of Accountable Care Organizations, but without community involvement in preventive health.

All together now!


All these entities will be taking a substantial leap of faith. But we believe they can succeed – especially if they work together through HICCup to figure out the numbers, study the effects of small-scale healthy-living/preventive health-care efforts, and encourage one another to move forward. Regardless, each investor must work with existing institutions – if only to get at the revenue stream initially and benefit from the lowered costs in later years.

Although grants are a nice source of funding for demonstration projects and research, the best way for HICCup’s vision to catch on and be widely copied is by adopting a for-profit approach that attracts broader investment once it is shown to work.  Indeed, if a benefactor makes a donation, they feel good when they send off the money. An investor feels good only after the investment actually pays off.

Community officials and voluntary organizations also need to sign on…or  they can drive the process and find the benefactor/investor. They will also contribute by implementing complementary changes in school meals and gym classes; enacting zoning and other changes to encourage cycling, walking, and the like; hiring health counselors and care workers; and perhaps working with local restaurants and food stores to subsidize healthy choices and discourage unhealthy ones.   Local media can report on the experiment’s progress, and each community will likely engage in healthy rivalry with other HICCup experimenters.

Though it won’t get to keep the direct health-care cost savings, each community will get all the ancillary benefits of a healthy population, including an enhanced reputation.  Indicators of population health include not just rates of obesity, diabetes, high blood pressure, and diseases and related costs, but also whether the elderly can live (and be cared for) at home, absenteeism, school grades and graduation rates, employment statistics, accidents, and the like. Although the funder keeps the reduction in health-care costs, the community gets the benefit in the many payoffs from a healthier population over time.

Open enrollment

HICCup will not choose which communities participate. They will be choosing them selves. HICCup’s role will be to advise them and help them to communicate and learn from other communities going through the same process. We also want to be a clearinghouse for vendors of health-oriented tools, services, and programs. There are many bargains to be struck between communities and vendors offering discounts in exchange for wholesale adoption of their tools or programs.

However, there is one unbreakable rule: To work with HICCup, communities must collect and publish a lot of independently vetted data (without personal information, of course). For starters, they will need benchmarks of current conditions and projected costs, and then detailed statistics on the adoption of the measures, their impact and costs, and what happens over time.  HICCup will welcome input from lawyers and actuaries!

It is now time to try this on a broad scale. Five years from now, we will wonder what took us so long to get started. So, again, who will those investors be?