Category Archives: healthcare

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
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, healthy habits, policy, politics, quotes & aphorisms

2014 AMA Health Priorities

Steve Hambleton
– population health
– reduce unwarranted clinical variation

Chris Baggoley
– dementia

Lesley Russell
– value-based payment

 

The five most pressing health priorities in 2014

21/01/2014

Trying to identify just five top priorities in an area as complex and ethically fraught as health care is a tough challenge, but that was the task Australian Medicine set for seven of the nation’s leading health advocates and thinkers, including AMA President Dr Steve Hambleton, the nation’s Chief Medical Officer Professor Chris Baggoley, health policy expert Dr Lesley Russell and World Medical Association Council chair Dr Mukesh Haikerwal. Here they provide their thought-provoking and insightful responses.

AMA President Dr Steve Hambleton

1.  Make population health a cross-portfolio priority for all levels of government
Population health is not just about treating illness. It’s also about keeping people well, and all portfolios (Agriculture, Defence, Education, Employment, Environment, Finance, Foreign Affairs and Trade, Health, Immigration and Border Protection, Industry, Infrastructure and Regional Development, Social Services, Treasury etc) need to do their part to fight the threat of non-communicable diseases which stem from tobacco, alcohol, over-nutrition and under- exercise.

2. Continue the investment in closing the life expectancy gap between Aboriginal and Torres Strait Islander peoples and all Australians
All governments need to keep up the investment, but not just in the health portfolio. There is stark evidence that investing in the social determinants of health and a good education, starting at birth, are major predictors of health outcomes.

3. Fix e-health and the PCEHR
We must be able to talk to each other in the same language -general practice, hospitals (public and private), public outpatients, private specialists, aged and community care. Too often the right message just does not get through. Let’s get the (e) rail gauge right and use it.

4. Reduce unwarranted clinical variation
The fastest way to save health dollars and achieve better outcomes is to (as Professor Lord Ari Darzi advised at the 2012 AMA National Conference) “close the gap between what we know and what we do”.  We know we are doing a good job and are very cost effective. If we embrace the move of learned colleges toward clinical audit and self-reflection we can make best practice even better.

5. Invest in research
The human papillomavirus vaccine will save millions of lives. Research delivered and refined the place of statins, also saving millions of lives. We need new ways of treating infections, perhaps more antibiotics or better ways to use the ones we already have.

Professor Chris Baggoley, Australian Government Chief Medical Officer

It is not easy to nominate five priority areas for action, given that there are so many deserving areas that require our ongoing attention. Of course, in my role there are a number of areas where my direct involvement is needed to help made a difference.
Understanding that this list excludes other equally deserving priority areas, my list is:
1. Antimicrobial Resistance, where concerns we are facing a post antibiotic era are widely shared across the globe. Australia is taking a leading role: we have adopted a One Health approach, a safety and quality approach (via the National Standards), and we are increasing our surveillance of resistant microbes and antimicrobial usage.

2. Emerging Infectious Diseases. The appearance of avian influenza H7N9 in China in 2013, and the Middle East Respiratory Syndrome Coronavirus in 2012-13, has redoubled the focus of all areas of the health system to prepare to manage emerging infectious diseases, and this must remain a focus for 2014.

3. Immunisation coverage. Public interest in the benefits of high levels of childhood immunisation was a particular feature of 2013, especially following the National Health Performance Authority report breaking coverage down to Medicare Local and postcode areas. Vaccine-preventable diseases should be prevented, and our attention to this aspect of health care in all areas must remain a priority.

4. Dementia. While the first three areas are part of my daily work, this is not the case for dementia. Nonetheless, the case for research into the causes and prevention of dementia is apparent to all of us.

5. Improving the nation’s mental health. Much work is underway to improve our mental health. Improved community and professional understanding and reduction in stigma will assist sufferers of mental health illness to seek help, and assist their recovery.

Dr Lesley Russell, Visiting Fellow, Australian Primary Health Care Research Institute, Australian National University

National

1. Addressing health disparities

Prime among these is the need to Close the Gap on health disparities for Indigenous Australians, but we should not forget the disparities suffered by people with mental illness, people with disabilities, the homeless, and those who are isolated, both geographically and socially. These gaps will only be closed by a broader focus on the social determinants of health through a whole-of-government approach.

2. Changing the way we pay for healthcare services

It’s time to move away from fee-for-service to a financing system that is (1) focused on value rather than volume; (2) rewards improved health outcomes and cognitive services as much as procedures; (3) encourages effective teamwork and collaboration; and (4) recognises time dedicated to education, mentoring, research, essential paperwork and communication.

3. Reworking the healthcare workforce

If we are to address the health and healthcare needs of the 21st century in a country as large and diverse as Australia, then we need an appropriate workforce and a system that enables every healthcare profession to work to full scope of practice. That means widening who can prescribe and who can work independently. The new workforce must include more Aboriginal and Community Health Workers to assist with outreach, education, care coordination and cultural sensitivity.

International

4. Antibiotic resistance

The growing threat of multiple resistance requires a major international effort involving the agriculture, food and health sectors and an increased focus on research to deliver solutions and new antibiotics.

5. Climate change

Everyone’s way of life and even national security is under threat from climate change. Developed nations like Australia must show leadership in tackling both the causes and the impacts. In the absence of government action, communities must step in to lead the way.

Professor Stephen Leeder, Professor of Public Health and Community Medicine, University of Sydney

1. National data collection and evaluation – the collection of national hospital safety and quality data is critical to monitoring the use of drugs and controlling the rise of drug-resistant infections. Information is also needed to track progress in preventive health, such as in addressing obesity. Repeated surveys, done by the same people using the same survey instruments, are needed to judge our progress.

2. We need to tell the story of what we are achieving in health care for the tens of billions we invest in it. The community who pays deserves to hear. Health Ministers need to enunciate what the goal of providing health care is, backed by stories that illustrate what is achieved every day in caring for people. These stories are needed to keep compassion alive in our democracy.  “Look where my Medicare tax dollar goes!” would be a great thing to boast about, and would enable ordinary taxpayers to see that their tax contributes to something of immense social value.

3. Fixing IT. We are 20 years behind best practice. We can see what it looks like in the US. It requires a huge investment, but the pay-off in quality is immense.

Martin Laverty, Chief Executive Officer, Catholic Health Australia

1. Causes of ill health need to constantly inform both health policy and practice. Two-thirds of Australians are overweight, 16 per cent of Australians smoke, and 13 per cent drink at levels of risk. Implementing Senate recommendations on social determinants of health would revive efforts to prevent Australians, particularly the most disadvantaged, from suffering avoidable chronic illness.

2. Coordination of health services around a person’s unique needs must become more of a priority, to improve patient outcomes and reduce waisted expenditure. Ideally, any person with an ongoing health complaint would have a health plan worked out and appropriately managed to focus on right treatment in the right place, ongoing medication management, avoidance of duplicated service, and prevention of further disease.

3. Health workforce constraints and industrial barriers still haven’t been resolved to ensure Australia will have enough medical, nursing, and allied health staff to meet Australia’s growing and ageing population. Role redesign of who does what in the health system remains essential, but as a nation we’re no closer to being able to solve workforce constraints because of entrenched industrial perspectives.

4. Consumer choice underpins the new National Disability Insurance Scheme, and is being introduced into home care for the aged. Better choice in health and aged care also needs attention, so that competition and contestability can drive improvements in financial and clinical outcomes.

5. End of life care needs the entire community’s attention. Health professionals and health consumers need to give new consideration to talking about, determining, and then implementing future care plans. Pastoral care for those in the final stages of life, indeed for any person dealing with significant illness, needs elevation as a priority for health and aged care providers.

Dr Mukesh Haikerwal, Chair of Council, World Medical Association, former AMA President

With a new federal administration in place, a fiscal Armageddon heralded and the health settings for Australia being less favourable, the usual troupe of kite-fliers have been showing their wares in the ‘silly season’. What I think we need is to secure the fundamentals and enhance and support sensible collaborative work practices.

1. Support more care out of hospital – don’t penalise quality holistic care in general practice.

Embed the notion of general practice as the bedrock, not only of primary health care and all out of hospital care, but also for health care delivery across the nation. The costs of the same care out of hospital, when appropriate, are a fraction of the cost in hospital.

2. Enhance hospitals and support the care provided there, and stop perverse penalties.

Support the existing hospital infrastructure that is struggling with the burden of increased demand and expectation from patients and from governments, which absurdly see them penalised for trying their hardest to cope with this. There needs to be a move from blame to re-setting costs and targets based on realistic care need evaluations, allowing for inevitable variation.

3. Embolden and formalise clinical leadership in health in a meaningful way.

Use clinical Senates – groups of cognisant, focussed individuals suggesting and supporting innovation in health care delivery. Enhance their work by trialling and evaluating changing concepts before whole-of-system adjustments, so that unforeseen consequences are outed and adjusted for in real situations with real doctors treating real patients.

4. Use e-health and telehealth logically in clinically safe and acceptable forms over and above the PCEHR, especially secure messaging delivery and web-based videoconferencing.  

Use innovative technologies in health (e-health and telemedicine) for clinical purposes, with clinical needs and drivers at the forefront. We do have potential technology to support and enhance (but not replace) trusted, proven good clinical methods. This is over and above, but could include, the PCEHR. Secure email to connect information is the key element.

5. Innovate with translational research in real clinical situations, proving concepts before rolling them out.

In care settings, sequential work across disciplines and health care establishments, with clinical participants nutting out how to best to innovate. Use just one set of agreed best practice guidelines that promote translational research that have been promulgated to, and agreed by, relevant medical groups. Make sure the economics and medicine are understood: it may cost more to implement in the beginning, but it will save on costs down the track.

Dr Brian Morton, Chair, AMA Council of General Practice

1. End of life care – There is an expectation that modern medical technology and care will extend life, but at what cost to the quality of life? The preparation of an Advanced Care Directive when competent will bridge this gap.

2. Lifestyle health issues – The genesis of many health issues are related to poor lifestyle choices which then require medical solutions. We need brave governments to implement public health interventions to de-medicalise preventive management.

3. Obesity – a whole-of-community response is required to manage the obesity “epidemic”, including responsible marketing and labelling of foods, appropriate food helping sizes, ready access to exercise programs, dietetic advice and legislative recognition that obesity is a risk factor for multiple chronic diseases.

4. Prostate cancer – A rational evidence-based and consensus approach is needed regarding screening and management.

5. Alcohol – A multifactorial societal approach is fundamental to alcohol management.

healthcare, policy, politics

PHI GP cover threatens budget and universality

“Aside from equity issues and potential distortions in the allocation and delivery of health services*, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.”

*HAH!!!

https://ama.com.au/ausmed/medibanks-gp-cover-threatens-universal-health

Medibank’s GP cover threatens universal health

21/01/2014

A Medibank Private scheme to give members privileged access to a range of GP services threatens to create a two-tier health system and could fracture the relationship patients have with their family doctor, the AMA has warned.

As the Federal Government proceeds with preparations for the sale of Medibank Private, it has been revealed by The Australian that in November the insurer commenced a trial with medical centre operator IPN in which its members are bulk-billed for GP consultations and get access to several service “enhancements”, including guaranteed appointments within 24 hours and after-hours home visits.

The arrangement is so far being trialled at six IPN clinics in south-east Queensland (including one at which AMA President Dr Steve Hambleton practises), and it circumvents a Private Health Insurance Act prohibition on insurers paying for services that are eligible for Medicare rebates by limiting Medibank Private funding to assistance with covering the administrative and management costs of the trial.

But AMA Council of General Practice Chair Dr Brian Morton said the scheme violated the spirit of the law, and corroded basic principles regarding equity of access to care.

Dr Morton said that although the AMA wanted to see health insurers more involved in primary health care, the approach being trialled by Medibank Private was flawed.

“We do want to involve private health insurers in general practice, but we don’t really see this as the best way of doing it,” Dr Morton told The Australian, adding that any provision to allowed funds to cover primary health services should be open to all patients and GPs.

Anticipating that private funds might seek to give their members privileged access to GP services, the AMA in 2006 released a Private Health Insurance and Primary Care Services Position Statement(https://ama.com.au/position-statement/private-health-insurance-and-primary-care-services-2006) setting out the parameters for the expansion of health fund into primary health care and the dangers that needed to be avoided.

In its Statement, the AMA said that a “limited” expansion of private insurers into primary care may be of some benefit, but only where it provides or pays for services not covered by Medicare.

“There are inherent risks in supporting an expansion of health insurance fund services into primary care,” the Position Statement said, noting especially that “limiting certain services to those who can afford private health insurance, particularly those related to preventive health measures, represents the establishment of a two-tiered system.”

Other concerns identified by the AMA included the potential for the focus of health services to shift from quality and continuity to cost cutting; for insurers to develop models for rationing care; for the development of imprecise patient selection techniques; for a shift away from the provision to patients of information and education “related to their health needs”; and for patients being encouraged to visit participating GPs, who may or may not be their regular family doctor.

In its Position Statement, the AMA warned that any scheme or arrangement that created such risks or undermined the universality and equity of Medicare “will be rejected by the medical profession”.

But so far the Federal Government has adopted a hands-off approach to the Medibank trial.

Health Minister Peter Dutton told The Age that he saw no evidence that the arrangement contravened the legislation, and appeared to give some encouragement to the initiative in a statement to The Australian Financial Review.

“I want every Australian to have a good relationship with their GP, so I wouldn’t rule out any changes,” Mr Dutton said. “Like the Australian Medical Association, I am open to greater involvement of the insurers, who cover 11 million Australians, to keep those people healthy and getting more regular access to primary care.”

Aside from equity issues and potential distortions in the allocation and delivery of health services, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In a note obtained by The Australian Financial Review, the Health Department in 2008 estimated the scheme would spur a 5 per cent increase in demand for GP services and GPs would increase their fees, adding a massive $3.4 billion to the Government’s Medicare rebate bill over five years.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.

The nation’s second largest health fund, Bupa, has joined the criticism, warning that although insurance cover for GPs charges would likely be a boon for providers, it would drive up the Government’s health bill.

The trial arrangement, and a suggestion that Medibank could assume responsibility for helping to administer the National Disability Insurance Scheme, has prompted speculation the Government is trying to boost the interest of investors in the purchase of the health fund, whose possible privatisation is currently the subject of a scoping study.

The pilot of private health cover for GP services has also come as the National Commission of Audit ponders a proposal for a $6 charge for GP visits [see also, $6 co-payment an illusory health saving].

Adrian Rollins

healthcare, healthy habits, meaning, musings, nutrition, policy, storytelling

Eternal youth for just $43K per day – or just exercise and eat well????

This is funny, only because for the super rich, this seems like a feasible way forward… instead of eating well and exercising. A really interesting insight into how broken our thinking on health truly is.

https://ama.com.au/ausmed/eternal-youth-may-be-yours-just-43000-day

Eternal youth may be yours, for just $43,000 a day

21/01/2014

Like a bad fairy tale, scientists believe they have developed a way to stop people getting older, but at a cost that puts it out of the reach of all but the super-rich.

A team of researchers at the University of New South Wales, working in collaboration with geneticists at Harvard Medical School, claim to have unlocked the secret to eternal youth, and to have developed a compound they say not only halts the ageing process, but can turn back the years.

The catch is, the treatment is prohibitively expensive, with estimates it would cost the average 86 kilogram man $43,000 a day, and the average 71 kilo woman $35,500 a day.

The compound was developed based on an understanding of how and why human cells age.

A series of molecular events enable communication inside cells between the mitochondria – the energy source for cells, enabling them to carry out key biological functions – and the nucleus. The researchers found that when there is a communication breakdown between the mitochondria and the nucleus of the cell, the ageing process accelerates.

As humans age, levels of the chemical NAD (which initiates communication between the mitochondria and the nucleus), decline. Until now, the only way to arrest this process has been through calorie-restricted diets and intensive exercise.

But the researchers, led by University of New South Wales and Harvard University molecular biologist Professor David Sinclair, have developed a compound – nicotinamide mononucleotide – that, when injected, transforms into NAD, repairing broken communication networks and rapidly restoring communication and mitochondria function.

In effect, it mimics the results achieved by eating well and exercising.

“The ageing process we discovered is like a married couple. When they are young, they communicate well but, over time, living in close quarters for many years, communication breaks down,” Professor Sinclair said. “And just like a couple, restoring communication solved the problem.”

In the study, the researchers used mice considered equivalent to a 60-year-old human and found that, within a week of receiving the compound, the mice resembled a 20-year-old in some aspects including the degree of muscle wastage, insulin resistance and inflammation.

Professor Sinclair said that, if the results stand, then ageing may be a reversible condition if it is caught early.

“It may be in the future that your age in years isn’t going to matter as much as your biological age,” Professor Sinclair said.

“What we’ve shown here is that you can turn back your biological age or, at least, we think we have found a way to do that.”

The problem is, the compound is prohibitively expensive, at least at the moment.

It costs $1000 per gram to produce, and in tests so far it has been applied at a rate equivalent to 500 milligrams for every kilogram of body weight, each day.

Professor Sinclair admitted the cost was major consideration, and said the team was looking at was to produce the compound more cheaply.

As part of their research, the scientists investigated HIF-1, an intrusive molecule that foils communication but also has a role in cancer.

It has been known for some time that HIF-1 is switched on in many cancers, but the researchers found it also switches on during ageing.

“We become cancer-like in our ageing process,” Professor Sinclair said. “Nobody has linked cancer and ageing like this before, and it may explain why the greatest risk of cancer is age.”

Researchers are now looking at longer-term outcomes the NAD-producing compound has on mice, and suggest human trials may begin as early as next year.

They are exploring whether, in addition to halting ageing, the compound can be used to safely treat a range of rare mitochondrial diseases and other conditions, such as cancer, type 1 and type 2 diabetes, muscular dystrophy, other muscle-wasting conditions and inflammatory diseases.

The research was published in the journal Cell.

Kirsty Waterford

healthcare, policy

US doctors not happy or satisfied with career

 

 

http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/

$1 million mistake: Becoming a doctor
ByKATHY KRISTOF  MONEYWATCH September 10, 2013, 1: 43 PM

 

ISTOCKPHOTO

(MoneyWatch) If you are brilliant, ambitious and gifted in science, you may consider becoming a doctor. If so, think twice. According to a new survey by personal finance site NerdWallet, most doctors are dissatisfied with the job, and less than half would choose a career in medicine if they were able to do it all over again.

There are many reasons for the dissatisfaction, said Christina Lamontagne, vice president of health at NerdWallet. Most doctors enter the field thinking they’ll be able to spend most of their time healing the sick. Yet the paperwork burden on doctors has become crushing, and could become even more complicated under the Affordable Care Act.

“Administrative tasks account for nearly one-quarter of a doctor’s day,” Lamontagne said. “With additional liability concerns and more layers in health care, we can understand the drain this takes.”

Play VIDEO

Doctor: Patients should take active role in care

Worse, the cost of becoming a doctor has soared, with higher education expenses leaving the average newly minted physician with $166,750 in medical school debt, while average salaries are declining. Nearly one-third of doctors — 28 percent – saw a cut in pay last year, according to NerdWallet’s research.

To be sure, pay is still high, with of six-figure positions in the country, according to government data. But it also takes between 11 and 14 years of higher education to become a physician. That means the typical doctor doesn’t earn a full-time salary until 10 years after the typical college graduate starts making money.

That lost decade of work costs a cool half-million dollars, if you assume this individual could have earned just $50,000 annually, and the typical medical school candidate is smart and successful enough to earn considerably more. Add in the time and cost it takes to pay off medical school debt and a dissatisfied physician may well consider pursuing medicine a $1 million mistake. (This assumes the average $166,750 medical school debt  takes 30 years to repay at 7.5 percent interest — a total cost of $419,738.)

Moreover, primary care physicians — those who go into pediatrics, family and internal medicine — earn barely more than the amount they accumulated in medical school debt, between $173,000 and $185,000, according to the study that looked at data from George Washington University’s School of Public Health, the American Association of Medical Colleges and Medscape.

The least satisfied physicians are those who go into internal medicine, according to the study. On average, these doctors see two patients every hour while spending 23 percent of their time on paperwork. They work an average of 54 hours per week, take home about $185,000 annually, and a fifth have seen a decrease in pay. Just 19 percent would choose the same specialty, and only one-third would choose a medical career if they had to do it over.

“The frustrations that patients have about not getting enough time with their doctor is mirrored by the frustration their doctors have with not having enough time to spend with their patients,” LaMontagne said.

The best paid doctors are orthopedic surgeons, who take home an average of $405,000 annually. The most satisfied appear to be neurologists, who earn an average of $216,000, while working an average of 55 hours per week. Sixty-percent would choose the same specialty, and 53 percent would go into medicine again. Oncologists — the doctors who treat cancer patients — are also generally satisfied with medicine and their jobs, with 62 percent saying that they would go into medicine and 57 percent reporting that they would choose oncology as a specialty.

Radiologists are the physicians most likely to have suffered a pay cut in the past year, with 42 percent reporting a decline in salary. However, they’re also among the best-paid doctors, earning an average of $349,000. More than half would both choose to be doctors again and choose the same specialty.

The doctors who work the longest hours are cardiologists, who report being on the job 60 hours per week. Some 54 percent would choose the same medical specialty, but only 44 percent would go into medicine again if they did it over. The average cardiologist earns $357,000 annually, though 39 percent have seen a cut in pay in the past year.

Those least likely to have suffered a pay cut are emergency doctors, who earn an average of $270,000 and work an average of 46 hours per week. Just 19 percent of emergency doctors suffered a cut last year, but only 41 percent would go into medicine or emergency medical care again.

Across all specialties, physicians see roughly 13 patients per day, work 52 hours per week and earn an average of $270,000. However, family and emergency doctors see nearly 75 percent more patients than anesthesiologists.

© 2013 CBS Interactive Inc.. All Rights Reserved.
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

healthcare, policy

Google backing telemedicine via Helpouts…

  • aligned with US DHHS
  • doesn’t support third party payments
  • asynchronous comms allows more convenience
  • pricing is pitched at co-pay levels
  • various other services discussed

http://www.fastcompany.com/3022450/the-doctor-veterinarian-and-lactation-specialist-will-see-you-now-on-video-chat

THE DOCTOR, VETERINARIAN, AND LACTATION SPECIALIST WILL SEE YOU NOW–ON VIDEO CHAT

WITH SERVICES LIKE GOOGLE HELPOUTS, HOUSE CALLS ARE BACK IN A BIG, MODERN WAY.

When Google launched Helpouts in November, it opened a marketplace for experts–from scrappy entrepreneurs to big-name brands such as makeup retailer Sephora–to share their skills over video chat.

Now, while some clueless consumers are simply looking for mascara tips, the search giant sees a vastly different industry that can benefit from the service: health care.

That’s right, in addition to the many musicians, yogis, and IT pros chatting on the Helpouts platform, there are also doctors, counselors, veterinarians, and lactation specialists, among other medical professionals. By melding parts of its infrastructure–namely Google Wallet and Hangouts–the company gives consumers a single destination, either through a computer or Android phone, to book sessions with experts and to pay for them. Doctors can even prescribe medicine, as Helpouts is aligned with the U.S. Department of Health and Human Services.

“We believe telehealth, and Helpouts, can complement in-person office appointments and play an important part in the overall continuum of care,” Google’s director of business operations, Christina Wire, tells Fast Company. “We look forward to learning how users find Helpouts to be most helpful in their continuum of care.”

Telemedicine isn’t exactly a new concept. Defined very broadly, the term can be applied to, say, African villagers who used smoke signals to warn others of disease outbreaks. More contemporary forms of telemedicine include the use of Xbox to care for patients with chronic illnesses and telepresence robots, such as the human-sizedRP-VITA from iRobot that lets doctors interact with patients from afar. But with the advent of mobile technologies, telemedicine has the potential to go mainstream.

Using Helpouts, San Francisco resident Justine Lam, 34, consulted One Medical Groupabout getting a flu shot while traveling in Austin early November. The first time she connected, the picture was fuzzy and the call dropped, but the second time, she got a hold of a nurse practitioner, who coincidentally happened to be the one she usually interacts with.

“I travel a lot for work, so it’s difficult for me to get to the doctor’s office,” says Lam, who formerly worked in marketing and recruiting for a tech company. “It was super easy. I just log in, find the time available, and within an hour I was seeing a medical professional.”

One Medical provides its services over Hangouts at no cost to its members; it charges non-members $40 to $60 per session. Dr. Kevin Fell is one of the staff members who now works a weekly shift where he’s on Helpouts duty. “Surprisingly, it feels very personal,” he says. “It feels like being a country doctor and making a really personal house call with the help of modern technology.”

Technology, Fell notes, may not quite replace humans just yet: “I still think the one-on-one physical meeting with a patient is still very important–always has been, always will be.”

Patients like Lam are turning to online platforms for less severe illnesses. And some providers are keen on servicing Telecure, a company focused on providing virtual urgent care. It joined Helpouts in November and only sees patients if they meet certain criteria. For example, they can’t have a fever exceeding 103 degrees or be sick for more than two weeks.

But there are also online platforms that aim to provide medical help beyond the common cold. Grand Rounds was cofounded by a blood clot specialist focused on cutting-edge advances in medicine, the type of treatment that on average takes 17 years to trickle into medical practices. “That’s been the bane of my existence,” cofounder Rusty Hofmann says. “I felt ethically compelled to start this company to fix this problem. The work that I do on blood clots was developed at Stanford in 1992, and 15 years later there were still hospitals 10 minutes away from Stanford not offering this treatment.”

Using the web, patients are able to consult with specialists, who review their medical history, imaging, lab tests, and other information before writing a four-page opinion describing the best course of action. Grand Rounds’ efficiency, Hofmann says, is dependent on asynchronous communication, allowing patients and doctors to use the platform without having to coordinate schedules while also giving doctors the time to research patients’ conditions.

One of the biggest obstacles standing in the way of broader telemedicine adoption is a familiar force: insurance companies. While President Obama hopes telemedicine can help reduce health care costs, the Affordable Care Act doesn’t go so far as to require insurers to pay for remote consultations. “Helpouts does not have a system in place to submit sessions to health insurance plans for reimbursement,” says Google’s Wire. “Reimbursement for Helpouts sessions is at the discretion of the health provider and the health plans they work with.”

Pearl.com, a 10-year-old online marketplace that started with a health care vertical, has tried to involve insurance providers for years. “We would love it if insurance companies would cover online doctors and telehealth,” says CEO and founder Andy Kurtzig, noting the site hit a major milestone in November with experts earning $100 million to date. “We would touch base once in a while, and the answer’s always no.”

Virtual health care companies try to make up for the lack of insurance coverage by pricing their services comparable to copays. Across the board, Pearl.com sessions begin at $15 and average about $30. Telecure prices its 15-minute sessions at a flat $25, and most consultations don’t exceed that, says CEO Garick Hismatullin. The company, in part because it doesn’t have an advertising budget, also added a way for patients to pay for their services with tweets–“social currency,” Hismatullin says. “We were looking for a way to make people more aware of our service,” he says, mentioning the pay-by-tweet option is available only on its site, not Helpouts. “This was a direct result of us watching thousands of incredibly satisfied patients, to let them do the talking for our company instead of paying for advertising.”

Helpouts is playing a role in hastening telemedicine’s adoption, but changes take time. “Services like Helpouts have the power to bring back doctor house visits after 50 years,” says Google’s Wire.

There will always be reason to physically go to a doctor’s office, but One Medical’s Fell is amazed at technology’s potential to transform health care. He recalls being at Mayo Medical School in the early ’90s and first hearing about telemedicine. “There was a doctor who said, ‘When you guys are older and in practice, you’re going to be able to see and meet with patients wherever they are, wherever you are,'” Fell remembers. “Most of us at the time, we didn’t even have an email address.”

[Base Images: Flickr users Phalinn Ooi & Official U.S. Navy]