Category Archives: politics

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The Hospital of the Future is not a Hospital

Great insights into where capital is being invested in US healthcare…

http://www.healthleadersmedia.com/print/LED-305089/The-Hospital-of-the-Future-is-Not-a-Hospital

The Hospital of the Future is Not a Hospital

Philip Betbeze, for HealthLeaders Media , May 30, 2014

Pursuing expensive inpatient volume in the traditional sense is a strategic dead end. Any new construction undertaken by hospitals and health systems should be based on adaptability, patient flow, and efficiency gains—not bed count.

I’ve spent a good deal of time the past several weeks interviewing senior healthcare leaders for my story in the May issue of HealthLeaders magazine about the hospital of the future. But in truth, that headline might be a bit of a tease.

As it turns out, the hospital of the future doesn’t look much like a hospital at all. Instead, it’s a cohesive amalgamation of plenty of outpatient modalities that represent growth in healthcare. Inpatient care, increasingly, represents stagnation and shrinkage, in the business sense.

In the past, a story about the hospital of the future has meant investigating healthcare organizations’ access to capital, and their ability to fund expensive new patient bed towers with all-private rooms and top technologies, in a race to grab volume from competitors.

Under that operating scenario, the sky was the limit, in terms of what organizations were willing to do to attract volume.

That calculus has changed drastically.

In a recent survey on healthcare design trends conducted by Minneapolis-based Mortenson Construction, 95% of the healthcare organizations surveyed said most of the projects they are undertaking are predominantly ambulatory in nature.

“If, in theory, the [Patient Protection and Affordable Care Act] has now got 7 million people engaged in healthcare insurance who didn’t have that previously, the inrush of patients will be outpatient-based,” says Larry Arndt, general manager of healthcare in the company’s Chicago offices. “What’s not needed is bed space or heavy procedural space.”

A Strategic Dead End
The PPACA, employers, and commercial health plans have made clear that pursuing expensive inpatient volume in the traditional sense is a strategic dead end. That doesn’t mean new patient towers won’t go up, but it does mean their construction will be based on adaptability, patient flow, and efficiency gains, not bed count.

As few as five to seven years ago, says Arndt, a healthcare leadership team would take a capital improvement project through a planning and programming phase in which they followed a traditional approach. The team would utilize widely standardized metrics and program their building based on what they’re doing now, with no consideration of the future, Arndt says.

By contrast, within the last five years, more leaders have been embracing the concept of lean operational improvement.

In order to be competitive in a limited amount of reimbursements, they have had to become more efficient. So instead of the traditional approach of programming new construction based on how the organization operates today, instead, it attempts to map out its current patient flows and discover how to become more efficient. Only then will the team look at how to build around that improved and more efficient model.

Indeed, a whopping 22% of respondents to Mortenson’s February survey said they were “doing nothing” construction-related right now, and only 5% were planning for a traditional replacement hospital.

Instead, a majority said they are focusing new construction on building clinics that can feature just about any outpatient modality except surgery, Arndt says.

Healthcare Shifts to Outside
They’re focusing on combining dialysis, radiology and other treatments that can be provided in one location. And they’re funneling more of their capital budget to items that are outside the realm of new construction, like home health and what Arndt calls e-home healthcare—in other words, technological solutions that help patients access their caregivers outside of any facility.

“Our customer understands that healthcare is moving more toward healthcare outside a facility,” says Arndt. “That means more money is being invested in health information technology. Also, you see more constellation or satellite projects, for example, a small 15,000-20,000 square-foot clinic in a neighborhood. That allows patients to travel a shorter distance to a less congested environment, but yet allows connection to the bigger facility if needed.”

Modular construction is a trend that Arndt sees developing quickly. It’s in the process of designing a clinic for a client that will feature modular walls, to make it more flexible for the changes in care protocols that are assured, but that healthcare’s leaders aren’t sure how will ultimately affect their competitive offerings.

In one clinic, doctors want to be able to meet with patients in groups, for example. Modular walls mean physicians can occasionally meet with groups of patients instead of individually, or vice-versa. Their space is less limiting.

“The clinic can adapt,” says Arndt.

Prefabricating buildings is also gaining steam in healthcare, he says.

“Money is being invested much more wisely than it has been in the past,” he says. “For the design/construction field, we have to be more lean too.”

Part of that lean attitude means offering customers 3-D modeling that starts with design partners, such as the people who will be staffing the building, to optimize work flow.

Adapting Takes Time
“We can prefab things we couldn’t years ago,” he says. An example might be a bathroom “pod” that can be built offsite and installed on site. Full exam rooms can be prepared the same way, and models can be constructed to test care protocols with the team that will be working there.

Arndt’s customers, he says, can be categorized two ways. Either they’re thinking broadly about adapting to the future without knowing exactly what it’s going to bring, or they’re standing idly on the sideline until they understand better how the PPACA and other drastic changes in how healthcare is provided and paid for will affect their bottom lines.

Neither approach is necessarily better than the other, but waiting just puts off the action that needs to be taken. It can be a prudent approach, but even in healthcare, what works can change quickly. Designing, building, and adapting still takes time.

Don’t wait too long.

Philip Betbeze is senior leadership editor with HealthLeaders Media. 

health market quality, healthcare, healthy habits, nutrition, policy, politics, quantified self, rapid learning health systems

Esther Dyson on the population health rampage!

 

http://www.healthleadersmedia.com/print/TEC-303509/Esther-Dyson-Launches-Population-Health-Challenge

Esther Dyson Launches Population Health Challenge

Scott Mace, for HealthLeaders Media , April 15, 2014

A tech investor with a proven track record of attracting innovation and money to a variety of endeavors is looking for a few good communities to compete for the greatest improvement in five measures of health and economic vitality.

Wellville

Healthcare ladies and gentlemen, start your communities.

That was the call on April 10 from angel investor and tech advisor Esther Dyson, whose population health dream has taken a big step toward reality with the launch of the Way to Wellvillecompetition.

From now until May 23, Dyson’s nonprofit startup, HICCup, is inviting communities to apply to be one of five contestants in a five-year-long competition to get healthy using everything from the latest fitness gadgets to reality TV. Dyson is HICCup’s founder and chairman of EDventure Holdings.

The 20-page application form is not for the casual applicant. Individuals or consultants need not apply – we’re talking community health organizations, other nonprofits or perhaps the local Better Business Bureau.

Esther Dyson’s Population Health Dream

Why bother? Several reasons. Dyson is an early investor in all sorts of innovative startups, with a proven track record of attracting innovation and money to a variety of endeavors over the past 25 years. She also is a great listener, having convened various listening sessions around the country last fall to get this latest idea off the ground.

Dyson’s fledgling organization, HICCup, found its footing in those sessions, and also a CEO, Rick Brush, who spent nearly a decade at Cigna, where he was chief strategy and marketing officer for the national employer segment and launched the payer’s Communities of Health venture.

Esther Dyson

Esther Dyson
Photo: courtesy of Joi on Flickr.

At one of those early scoping sessions, Brush asked the kinds of tough questions about what Way to Wellville should be measuring that landed the answers in HICCup’s FAQ and himself in the CEO’s chair, Dyson tells me.

A ‘Learning Lab for Health’
“What we’re trying to do is almost create a learning lab for health with subsidiary projects and contests along with the five-year marathon,” Dyson says.

Back to that lengthy application, which goes beyond asking about a community’s healthcare, straight to the health of a community, seeking such metrics as percentage of temporary residents, household income, poverty levels, and a slew of outcomes data – percentages of a community with diabetes, heart disease, asthma, smoking status, obesity and more.

Applicants also have to describe their top previous successes and failures trying to improve community health, healthcare financing innovations such as ACOs, patient-centered medical homes, population health, bundled payments, and so on.

In other words, it’s a lot of the things that HealthLeaders readers are currently embarking on both individually and collectively. And if the prestige of being selected for the first-of-its-kind national competition of sorts doesn’t intrigue you, there are a couple of other things to consider.

First is the cash prize at the end of the five years. HICCup itself won’t be rewarding such a prize, but hopes to raise $5 million for it. “Honestly, contestants are going to have to spend $15 to $50 million as a community to do this, so you’re not doing this for the prize, though of course it matters to some extent,” Dyson says.

Second, and more importantly, Way to Wellville contestants will become part of a larger community amongst the five competing communities. They will meet face-to-face in September at an annual conference, Next Step to Wellville, about a month after the five competing communities are selected.

The actual judging of who wins in 2019 has yet to be decided, but it will be a third party for legal and fiduciary reasons. Dyson emphasizes that the organization doesn’t have all the answers yet.

Metrics Matter
If you believe, like I do, that healthcare is closer than ever to some tectonic shakeups courtesy of technology, then Way to Wellville is likely to be a great observation post. Innovative medical hardware and software companies are already flocking to a variety of competitions such as this. Way to Wellville is just taking a bigger view of what kind of population health solutions will ultimately be necessary.

Expect also a lot of intermediate measurements and competitions.

“We’re hoping that some of these quantified self vendors will come in and donate devices to the communities and so we’ll have Fitbit and Fuelband contests,” Dyson says. “[Add to that] the county health rankings and all of these sorts of official measures, most of which are a year or two old, and we’re all going to get a lot more real-time data.”

“You can’t report transitions to diabetes every month,” Dyson says, “so there will be some health measures that are kind of yearly, but then there are, the outcomes measures tend to be slow. The input measures, like the percentage of school lunches that contain no French fries or something, you can measure in more real time.”

The $15 to $50 million table stakes per community sounds daunting to me. “It’s not the community goes and gets a $50 million grant from somebody,” Dyson says. “It’s more than they get a $10 million grant for, let’s say, heart health. There’s a $2 million program for food subsidies for fruits and vegetables. There are accountable care organizations that find an investor to improve the health so that their costs go down. There are social impact bonds.”

Philanthropists Wanted
“So it’s a combination of a large number of different kinds of funding from donors, from social investors, from vendors giving in-kind services or goods, and maybe in outer years, the school board raises a bond to do something with the school lunch. Each community is going to need to get money and support from a variety of courses in a variety of funds.

“We’ll be looking for people who want to invest in various ways of producing health. We’re also looking for donors [and] philanthropists.”

And of course, Dyson is reaching out to her famous set of angel investor friends. The goal, of course, is to go beyond that. Another way to maintain excitement on Dyson’s agenda is “a cheesy reality TV show” and perhaps a documentary.

As we see more and more crowdfunded efforts springing up in healthcare technology, Dyson’s approach has some similarities – with perhaps a crowd with deeper pockets, or at least one that’s been around the startup block a time or two.

Dyson hopes for up to 50 applicants for the five spots, and already has solid interest from several communities. Her population health dream is alive, and by this fall we should start to see some manifestations of it.

Scott Mace is senior technology editor at HealthLeaders Media. 

healthy habits, nutrition, policy, politics

Eating more fruit and veg won’t stop obesity

 

http://www.theatlantic.com/health/archive/2014/06/eating-more-fruits-and-vegetables-wont-stop-obesity/371992/

Eating More Fruits and Vegetables Won’t Stop Obesity

People have been eating more fresh produce as the obesity epidemic has worsened. They’ve been eating more of everything else, too.
(matt)/Flickr

Why are so many people overweight? Part of the reason, some think, is because they don’t have access to, the money to buy, or the desire to eat fresh fruits and vegetables.

That’s the idea behind initiatives like the “One more a day pledge” (whose slogan sounds like the pledge-taker might already be choking on carrots: “I pledge to eat … and help my family eat … at least ONE MORE fruit or veggie every day.”[ellipses sic])

Produce is less calorically dense than grains, meat, and fat, so increasing its consumption might indeed make sense as an obesity-fighting strategy—that is, if eating more fruits and vegetables caused people to compensate by eating fewer cookies and french fries.

Unfortunately, though, we don’t really eat that way. We’ll have a tossed salad—and then a Chipotle Quesarito. At least, that’s what RAND health economist Roland Sturm found in a new paper he co-authored with Ruopeng An, a health policy professor at the University of Illinois at Urbana-Champaign.

“Conventional wisdom is an awful guide for policy,” Sturm told me. “The consumption of fruits and vegetables has increased during the obesity epidemic.”

Differences in diet, such as eating more Cheetos and fewer cucumbers, help explain why some individuals are more obese than others, Sturm said. But they don’t explain why obesity has grown across all populations in nearly all U.S. states over the past few decades.

The study, published in the journal CA: A Cancer Journal for Clinicians, found that while college-educated people are still less likely to be obese than their less-educated counterparts, they’re still fatter than they used to be:

Increase in body mass index over time for people of various levels of education (CA: A Cancer Journal)

And the BMIs of the uber-healthy Coloradans, who regularly appear on “healthiest states” lists, have been rising over time, just like those of Mississippians have:

Prevalence of overweight over time in California, Colorado, and Mississippi. (CA: A Cancer Journal)

Today, people eat about 30 more pounds of vegetables and 25 more pounds of fruit per year than they did in 1970, according to Sturm’s calculations.

Unfortunately, they’re eating more of everything else, too. The average adult consumed about 2,100 calories in 1970, but in recent years that number has risen to more than 2,500.

Average daily per capita calories, adjusted for waste (CA: A Cancer Journal for Clinicians)

Attempts to discourage the consumption of certain macronutrients also don’t seem to work. Historically, people have simply eaten less of the forbidden substance and more of the others. During the low-fat craze of the 90s, for example, fat consumption dipped, but carbohydrate intake skyrocketed. And after the Atkins diet took off in 2000, people simply swapped carbs back in for fat.

Change in macronutrient consumption over time. (CA: A Cancer Journal for Clinicians)

“Preventing obesity is not about eating more food, regardless of how many nutrients it provides,” Sturm and An write, “but consuming less energy or expending more.”

Past research on the produce-obesity issue has been mixed: A 2003 study of a large sample of children found that eating more fruits and vegetables had no significant impact on weight. Around the same time, a different study of middle-aged nurses found those who ate more produce were less likely to become obese.

Sturm emphasized that his study is different because it’s looking at top-level changes over time, not disparities between groups of people.

A recent Lancet study found that rich and poor countries alike are now struggling with obesity, and that there have been “no national success stories” in stemming the epidemic. So while it’s definitely a problem that, say, poor American women tend to be fatter than richer women, another frightening trend is the overall rise of large waistlines over time.

data saving lives, entrepreneurship, facts & data points, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems

Wired Health – Proteus Digital Pill Presentation

Proteus occupy an interesting position… ingestibles are the ultimate in wearables. It’s smart also to be backed a big flailing incumbent player. It will be interesting to see if this stuff works.

http://www.proteus.com/andrew-thompson-on-transforming-healthcare-at-wired-health-2014/

Andrew Thompson on transforming healthcare at Wired Health 2014

Published On: May 5, 2014

Watch Proteus CEO Andrew Thompson present at Wired Health 2014 on transforming healthcare through digital medicines:  http://bit.ly/1lS7RLe 

WIRED Health is a one-day summit designed to introduce, explain and predict the coming trends facing the medical and personal healthcare industries. The inaugural event was held on Tuesday April 29, at the new home of the Royal College of General Practitioners, 30 Euston Square, London.Andrew Thompson at Wired

healthcare, healthy habits, policy, politics

Peter Martin nails the daftness of the budget health cuts…

…with some help from SRL. The  last par nails it:

Withdrawing from  measures we know will work in order to fund new measures we think might work seems a daft way to manage our health. But it’ll help cut the deficit.

http://www.smh.com.au/comment/when-deep-cuts-are-not-healthy-20140602-zrukf.html

When deep cuts are not healthy

Date

Economics Editor, The Age

View more articles from Peter Martin

Illustration: Andrew Dyson

Illustration: Andrew Dyson.

It took Mark Latham to say the unsayable. “If a cure to cancer is to be found, most likely it will happen in Europe or the United States,” he wrote in the Weekend Financial Review. Spending scarce funds to find a cure ourselves is a waste of money, a political fig leaf to cover the electoral pain of the GP co-payment.

Anyone who doubts that the Medical Research Future Fund is a fig leaf or an afterthought, needs to only look at the pattern of leaks and speeches leading up to the budget. Ministers spoke often about the need to restrain the cost of Medicare, scarcely at all about the need to boost medical research.

They weren’t able to prepare the way for the medical research future fund because it didn’t come first. It isn’t that pharmaceutical benefits, doctors rebates and future hospital funding are being cut to pay for the fund. It’s that the fund was evoked late in the piece to smooth the edges of the cuts.

Under the descriptions of 23 separate cuts in the budget are  the words: “The savings from this measure will be invested by the government in the Medical Research Future Fund”.

The cuts hit dental health, mental health, funding for eye examinations, measures to improve diagnostic images, research into preventive health, a trial of e-health and $55 billion of hospital funding over the next 10 years.

We’re told the cuts are to build a $20 billion Medical Research Future Fund, but the immediate purpose is to cut the deficit.

The wonders of budget accounting mean that the savings notionally allocated to the fund will actually be used to bring down the budget deficit except for when money is withdrawn from the fund to pay for research.

It’s the same trick Peter Costello pulled with the Future Fund. The government gets two gold stars for the price of one. It can both cut the deficit and build up the funds for medical research. And it isn’t yet too sure about what type of research.

Under questioning by senators on Monday, health department officials revealed that they didn’t even know about the fund until late in the budget process and even then provided no advice on how it would work.

Asked about the kind of things the fund would finance, the department’s secretary Jane Halton said the questions were hypothetical.

Would it include evaluations of potentially life-saving preventive health measures such as SunSmart and anti-tobacco programs? “I think it’s unlikely based on the description I have seen, but again we are in an area that we probably can’t yet answer,” she replied.

A few minutes later she asked for her words to be expunged saying she really didn’t know. “We need to work through this level of detail” she told the senators.

We know that cures for cancer, Alzheimer’s and heart disease will be part of fund’s remit, because the Treasurer told us so. “One day someone will find a cure for cancer,” he said after the budget. “Let it be an Australian and let it be us investing in our own health care.”

Latham’s point is that the idea is silly. By all means contribute proportionately to a global effort to find cures for diseases, but don’t try and lead the pack by taking scarce dollars away from applying the medical lessons we have already learnt.

Small countries like Australia are for the most part users rather than creators of technology, and our funds are limited as Joe Hockey well knows.

The Medical Journal of Australia isn’t fooled. This month’s editorial says a government genuinely concerned about extending the working lives of Australians would be investing more in preventing chronic disease, not less.

“The direct effects of the proposed federal budget on prevention include cuts to funding for the National Partnership Agreement on Preventive Health, loss of much of the money previously administered through the now-defunct Australian National Preventive Health Agency, and reductions in social media campaigns, for example, on smoking cessation,” it says.

“Increased funding for bowel cancer screening, the Sporting Schools initiative, the proposed National Diabetes Strategy and for dementia research are positive developments, but do not balance the losses.”

It’s the indirect effects of the measures the fund seeks to make palatable that have it really worried. The $7 co-payment will work out at $14 for patients with chronic diseases. They’ll pay once to see the doctor and then again to have a test. The editorial quoted four studies which have each found that visits for preventive reasons are the ones co-payments are most likely to cut back.

“The effects of these co-payments on preventive behaviour are greatest among those who can least afford the additional costs,” it observes. Which is a pity because “the potential for prevention is greatest among poorer patients, who are often at a health disadvantage”.

We’ll all suffer if co-payments cut vaccination rates, even those of us who aren’t poor, and even if the Medical Research Future Fund finds a cure cancer.

The journal’s biggest concern is that the cuts to hospital services will hit preventive health measures because they are seen as less urgent.

“The greatest pity of all is that the proposed cuts to funding for health come at the time when the first evidence is at hand of potential benefits of the large-scale preventive programs implemented under the national partnership agreements,” the journal writes. “A slowing in the rate of increase in childhood obesity and reductions in smoking rates among indigenous populations have been hard-won achievements.”

Withdrawing from  measures we know will work in order to fund new measures we think might work seems a daft way to manage our health. But it’ll help cut the deficit.

Peter Martin is economics editor of The Age.

Twitter: @1petermartin

healthcare, policy, politics

Doggett backs in Professor Halton

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

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

Also annoying to see Terry continuing to dig a hole:

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Endoscopic overservicing

 

Upper endoscopies may bilk Medicare

May 24, 2014 | By 

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

Peter Ubel

Peter Ubel, Contributor

I explore medical controversies thru behavioral econ and bioethics.

5/22/2014 @ 11:23AM |801 views

Inappropriate Medicare Incentives Lead To Unnecessary Subspecialty Procedures

Comment Now

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

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

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

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

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

repeat upper endoscopies

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

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

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

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

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

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

 

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

The case for eating steak and cream

 

 

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

Economist Book Review

The Case For Eating Steak and Cream

Shifting the argument

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

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

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

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

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

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

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

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