Category Archives: healthcare

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

New Yorker: Good medicine, it seems, does not always feel good.

This is weird… it’s like doctors are calling themselves out as hucksters? Unable to manage conflicts of interest? Human?? In which case, they can stop carrying on as if they’re something superior.

http://www.newyorker.com/online/blogs/elements/2013/07/when-doctors-tell-patients-what-they-dont-want-to-hear.html

JULY 23, 2013

WHEN DOCTORS TELL PATIENTS WHAT THEY DON’T WANT TO HEAR

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There’s an episode of “The Mindy Project,” Mindy Kaling’s comedy about the life of an obstetrician, that begins in the office of an attractive ob-gyn, Dr. Reed. He sits, beaming, in front of his pregnant patient and her husband. He wears a crown of jewels they have given him, and they exchange pleasantries until the inevitable moment arrives: they need to address the patient’s health. She is obese, and her weight poses many risks to the fetus.

Unwilling to jeopardize the affection of his “favorite patient,” Dr. Reed instead summons the brazen and socially inept Dr. Mindy to do his dirty work. True to form, by the end of the scene, Mindy has offended the patient, which escalates into a shouting match until the patient tells Mindy that she’s the one who needs to lose some weight. Reed emerges, halo intact.

Though the scene marks a bad day for Mindy, I think it also heralds what could turn out to be a bad era for American medicine. Beyond the comedic exaggerations lies an age-old tension: Will our patients still like us if we tell them things they don’t want to hear? The challenge of communicating unpleasant, possibly profoundly upsetting information to patients is timeless. What has changed, however, is that physicians are now being judged, and compensated, based upon their ability to do it.

In October, 2012, Medicare débuted a new hospital-payment system, known as Value-Based Purchasing, which ties a portion of hospital reimbursement to scores on a host of quality measures; thirty per cent of the hospital’s score is based on patient satisfaction. New York City’s public hospitals recently decided to follow suit, taking the incentive scheme one step further: physicians’ salaries will be directly linked to patients’ outcomes, including their satisfaction. Other outpatient practices across the country have also started to base physician pay partly on satisfaction scores, a trend that is expected to grow.

But in a country that spends more per capita on health than any other, with results that remain mediocre in comparison, can we really expect that a nation of more satisfied patients will be a healthier nation over all?

Many insist that we can. One of the leading arguments for pay based on satisfaction, as described in a recent Wall Street Journal article titled “The Talking Cure for Health Care,” is that these incentives will improve patient-doctor communication, which will in turn lead to better health. As the article notes, “Doctors are rude. Doctors don’t listen. Doctors have no time. Doctors don’t explain things in terms patients understand.”

Few object to these generalizations. We’ve all had insensitive doctors who have left us confused and scared. I’m a physician, and I often find myself rushing, interrupting, and overwhelming patients with information. But if the path from good communication to better health is through a better understanding of risk factors and disease, then medicine poses a paradox: how much we understand tends to be inversely related to how well we think physicians have communicated.

Consider, for example, a recent study among patients with chronic kidney disease: the more knowledge patients had about their illness, the less satisfied they were with their doctors’ communication. Another study’s title asks, “How does feeling informed relate to being informed?” The answer: it doesn’t. The investigators surveyed over twenty-five hundred patients about decisions they had made in the previous two years, and found no over-all relationship between how informed patients felt and what they actually knew.

The disconnect between patients’ understanding of disease and their satisfaction with physicians is particularly pronounced for care at the end of life. In a recent study published in the New England Journal of Medicine, oncologists studied patients’ expectations of chemotherapy options. For these patients, with either end-stage colon or lung cancer, chemotherapy may provide some help, but it can also be toxic, and definitely doesn’t provide a cure. Doctors know this, but do patients?

In the study, sixty-nine per cent of patients with lung cancer, and eighty-one per cent of patients with colon cancer, did not understand that chemotherapy was not curative. This finding reminds that we have much to learn about how to communicate medical information to our patients. But it is the second finding that suggests why paying based on patient satisfaction isn’t the way to get us there: the more people understood about the grim nature of their prognosis, the less they liked their physicians.

Understanding that there is no cure for your disease is entirely different from understanding why you need to take a blood-pressure medication. Since I suspect that a bit of denial is precisely what allows the dying to live—see the response of a young, pregnant woman to the news that she has incurable lung cancer in Atul Gawande’s “Letting Go” for a beautiful example—I tend to be more concerned with how to keep people from getting sick in the first place.

And this gets us back to the Mindy problem. Sure, there are nice ways of saying, “You need to lose weight, stop smoking, and take this medication that certainly won’t make you feel better but might very well leave you tired and depressed.” But sometimes there aren’t, and it can be tough to separate how we feel about the message from how we feel about the messenger.

I used to be an avid runner, but have had a slew of running injuries—the most enduring of which is a chronic hamstring problem that has made sitting uncomfortable, and running impossible. But for a long time, my approach to any given injury was simple: run through it.

In my quest for quick fixes, I have seen more orthopedists than I can count. But there was one doctor, Dr. D., who tried to teach me the error of my ways. He told me that the problem was not with my body but with my behavior. He said I didn’t need MRIs or steroid injections but rather to stop running and give myself time to heal. And I, in turn, found much that was wrong with him: he started late, didn’t return phone calls, had bad breath, typed with one finger, and, above all, didn’t seem to listen to me. I decided he was the worst doctor in the world and went searching for a new one.

Many months and doctors later, last year, I found “my person.” Most important, she told me I would run again. That she was so nice, so pretty, and so put together (and she injected my aching gluteal region with steroid every time I asked) only reinforced my sense that I was in the most expert of hands. I loved her as much as I wanted to be her.

If you had mailed me a satisfaction survey, you can imagine which doctor would have gotten a bonus. But in the end, it’s Dr. D who was right. I still can’t run, but had I heeded his advice, I’d likely be back to doing marathons.

The problem with the patient-satisfaction surveys is that they assume we can evaluate specific characteristics of doctors, or hospitals, as distinct from their general likability. But that’s not easy. The halo effect is a well known cognitive bias that describes our tendency to quickly judge people and then assume the person possesses other good or bad qualities consistent with that general impression. The effect is perhaps best described in the many positive attributes we ascribe to someone we find attractive. As the Nobel laureate Daniel Kahneman noted, for example, “If we think a baseball pitcher is handsome and athletic … we are likely to rate him better at throwing the ball, too.”

This tendency has been well demonstrated in our judgments of the competence of political candidates, or our willingness to assume innocence for someone accused of a crime. (See Paul Bloom’s post on the unwarranted empathic response to the attractive face of the Boston Marathon bomber Dzokhar Tzarnaev.) Though there are several factors informing the general likability of physicians beyond how we feel about what they tell us, there is no reason to assume we would be somehow immune to this cognitive bias when it comes time to rate them.

Although we tend to be totally unaware of the effects of these haloes on our own judgments, hospitals and outpatient practices are not. That’s why they are investing millions of dollars in renovated rooms, new foyers, gourmet chefs, and valet parking. These are nice perks, and undoubtedly lead to higher scores across all domains of the satisfaction survey.

But do higher scores on a satisfaction survey translate into better health? So far, the answer seems to be no. A recent study examined patient satisfaction among more than fifty thousand patients over a seven-year period, and two findings were notable. The first was that the most satisfied patients incurred the highest costs. The second was that the most satisfied patients had the highest rates of mortality. While with studies like this one it is always critical to remember that correlation does not equal causation, the data should give us pause. Good medicine, it seems, does not always feel good.

Lisa Rosenbaum is a cardiologist, a Fellow at the Philadelphia V.A. Medical Center, and a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania.

Photograph: Fox

complex adaptive systems, facts & data points, health market quality, healthcare, healthy habits, policy, politics, rapid learning health systems, storytelling

The many reasons why the US is losing in health

  • very interesting piece
  • covers off Cth Fund and IOM comparative work
  • also discusses social determinants, and specifically the idea that less equal societies are comparatively less healthy across the board (including the wealthy)
  • The critical importance of poverty prevalence in a country’s health (AU is 12.5% c.f. average of 9% cf. US of 15%)

Woolf explained this disparity by citing the work of the British social epidemiologist Richard Wilkinson, who has proposed that income inequality generates adverse health effects even among the affluent. Wide gaps in income, Wilkinson argues, diminish our trust in others and our sense of community, producing, among other things, a tendency to underinvest in social infrastructure. Furthermore, Woolf told me, even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress. Consider the example of paid parental leave, for which the United States ranks dead last among O.E.C.D. countries. It’s not hard to see how such policies might have implications for infant and child health.

  • Political systems have important effects on policy:  fewer “choke points for special interests to block or reshape legislation,” such as filibusters or Presidential vetoes allows change to be enacted without extensive political negotiation.

Other countries have used their governments as instruments to improve health—including, but not limited to, the development of universal health insurance. Health-policy analysts have therefore considered the effect that different political systems have on public health. Most O.E.C.D. countries, for example, have parliamentary systems, where the party that wins the majority of seats in the legislature forms the government. Because of this overlap of the legislative and executive branches, parliamentary systems have fewer checks and balances—fewer of what Victor Fuchs, a health economist at Stanford, calls “choke points for special interests to block or reshape legislation,” such as filibusters or Presidential vetoes. In a parliamentary system, change can be enacted without extensive political negotiation—whereas the American system was designed, at least in part, to avoid the concentration of power that can produce such swift changes.

  • universal health coverage is not just altruistic, but also self-interested
  • healthcare is only responsible for between 10 and 25% of improvements in life expectancy – SDH responsible for the rest, mainly elements that impact on early childhood

Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.

 

 

 

http://www.newyorker.com/online/blogs/elements/2014/06/why-america-is-losing-the-health-race.html

JUNE 13, 2014

WHY AMERICA IS LOSING THE HEALTH RACE

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Many Americans are aware that the United States spends much more on health care than any other country in the world. But fewer people know that the health of Americans—by many different measures—is actually worse than the health of citizens in other wealthy countries.Two major reports, both released last year, provide further elaboration of this apparent paradox. The first, “The State of US Health, 1990-2010,” documented trends in mortality and morbidity across the thirty-four member countries of the Organization for Economic Cooperation and Development (O.E.C.D.). The study, published in The Journal of the American Medical Association (to which I am a contributing writer), showed that both life expectancy and healthy-life expectancy improved in the United States over two decades. But the pace of those improvements was considerably slower in the United States: in 1990, the U.S. ranked twentieth among O.E.C.D. countries for life expectancy, and fourteenth for healthy-life expectancy; by 2010, it had fallen to twenty-seventh and twenty-sixth, respectively. The other charts and tables in the report—about heart, lung, and kidney disease; diabetes; injuries and homicides; depression; and drug abuse—all show Americans suffering poorer health.

The second report, commissioned by the National Institutes of Health, and conducted by the National Research Council (NRC) and the Institute of Medicine (IOM), convened a panel of experts to examine health indicators in seventeen high-income countries. It found the United States in a similarly poor position: American men had the lowest life expectancy, and American women the second-lowest. In some ways, these reports were not news. As early as the nineteen-seventies, a group of leading health analysts had noted the discrepancy between American health spending and outcomes in a book called “Doing Better and Feeling Worse: Health in the United States.” From this perspective, the U.S. has been doing something wrong for a long time. But, as the first of these two reports shows, the gap is widening; despite spending more than any other country, America ranks very poorly in international comparisons of health. The second report may provide an answer—supporting the intuition long held by researchers that social circumstances, especially income, have a significant effect on health outcomes.

Americans’ health disadvantage actually begins at birth: the U.S. has the highest rates of infant mortality among high-income countries, and ranks poorly on other indicators such as low birth weight. In fact, children born in the United States have a lower chance of surviving to the age of five than children born in any other wealthy nation—a fact that will almost certainly come as a shock to most Americans. But what causes such poor health outcomes among American children, and how can those outcomes be improved? Public-health experts focus on the “social determinants of health”—factors that shape people’s health beyond their lifestyle choices and medical treatments. These include education, income, job security, working conditions, early-childhood development, food insecurity, housing, and the social safety net.

Steven Schroeder, the former president of the Robert Wood Johnson Foundation—the largest philanthropic organization in the United States devoted to health issues—had a definitive answer to my question about why Americans might be less healthy than their developed-country counterparts. “Poverty,” he said. “The United States has proportionately more poor people, and the gap between rich and poor is widening.” Seventeen per cent of Americans live in poverty; the median figure for other O.E.C.D. countries is only nine percent. For three decades, America has had the highest rate of child poverty of any wealthy nation.

Steven Woolf, of Virginia Commonwealth University, who chaired the panel that produced the NRC-IOM report, also pointed to poverty when I asked him to explain the causes of America’s health disadvantage. “Could there possibly be a common thread that leads Americans to have higher rates of infant mortality, more deaths from car crashes and gun violence, more heart disease, more AIDS, and more premature deaths from drugs and alcohol? Is there some common denominator?” he asked. “One possibility is the way Americans, as a society, manage their affairs. Many Americans embrace rugged individualism and reject restrictions on behaviors that pose risks to health. There is less of a sense of solidarity, especially with vulnerable populations.” As a percentage of G.D.P., Woolf observed, the U.S. invests less than other wealthy countries in social programs like parental leave and early-childhood education, and there is strong resistance to paying taxes to finance such programs. The U.S. ranks first among O.E.C.D. countries in health-care expenditures, but as Elizabeth Bradley, a researcher at Yale, has documented, it ranks twenty-fifth in spending on social services.

The NRC-IOM report emphasized the effect of social forces on children and how those forces carry over to affect the health of adults, noting that American children are “more likely than children in peer countries to grow up in poverty” and that “poor social conditions during childhood precipitate a chain of adverse life events.” For example, of the seventeen wealthy democracies included in the report, the U.S. has the highest rates of adolescent pregnancy and sexually transmitted diseases, and the second-highest prevalence of H.I.V. This platform of adverse health influences in childhood sets up the health disadvantage that remains pervasive for all age groups under seventy-five in the United States.

It seems likely that many Americans would respond to these figures—and to the role poverty plays in poor health outcomes—by assuming that the data for all Americans is being skewed downward by the health of the poorest. That is, they understand that poor Americans have worse health, and presume that, because the United States has more poor people than other wealthy countries, the average health looks worse. But one of the most interesting findings in the NRC-IOM report is that even white, college-educated, high-income Americans with healthy behaviors have worse health than their counterparts in other wealthy countries.

Woolf explained this disparity by citing the work of the British social epidemiologist Richard Wilkinson, who has proposed that income inequality generates adverse health effects even among the affluent. Wide gaps in income, Wilkinson argues, diminish our trust in others and our sense of community, producing, among other things, a tendency to underinvest in social infrastructure. Furthermore, Woolf told me, even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress. Consider the example of paid parental leave, for which the United States ranks dead last among O.E.C.D. countries. It’s not hard to see how such policies might have implications for infant and child health.

Other countries have used their governments as instruments to improve health—including, but not limited to, the development of universal health insurance. Health-policy analysts have therefore considered the effect that different political systems have on public health. Most O.E.C.D. countries, for example, have parliamentary systems, where the party that wins the majority of seats in the legislature forms the government. Because of this overlap of the legislative and executive branches, parliamentary systems have fewer checks and balances—fewer of what Victor Fuchs, a health economist at Stanford, calls “choke points for special interests to block or reshape legislation,” such as filibusters or Presidential vetoes. In a parliamentary system, change can be enacted without extensive political negotiation—whereas the American system was designed, at least in part, to avoid the concentration of power that can produce such swift changes.

Whatever the political obstacles, a major explanation for America’s persistent health disadvantage is simply a lack of public awareness. “Little is likely to happen until the American public is informed about this issue,” the authors of the NRC-IOM report noted. “Why don’t Americans know that children born here are less likely to reach the age of five than children born in other high income countries?” Woolf asked. I suggested that perhaps people believe that the problem is restricted to other people’s children. He said, “We are talking about their children and their health too.”

The superior health outcomes achieved by other wealthy countries demonstrate that Americans are—to use the language of negotiators—“leaving years of life on the table.” The causes of this problem are many: poverty, widening income disparity, underinvestment in social infrastructure, lack of health insurance coverage and access to health care. Expanding insurance coverage under the Affordable Care Act will help, but pouring more money into health care is not the only answer. Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.

Self-interest may be a natural human trait, but when it comes to public health other countries are showing the U.S. that what appears at first to be an altruistic concern for the health and care of the most vulnerable—especially children—may well result in improved health for all members of a society, including the affluent. Until Americans find their way to understanding this dynamic, and figure out how to mobilize public opinion in its favor, they will all continue to lose out on better health and longer lives.

 

Allan S. Detsky (M.D., Ph.D.) is a general internist and a professor of Health Policy Management and Evaluation and of Medicine at the University of Toronto, where he was formerly physician-in-chief at Mount Sinai Hospital. He is a contributing writer for The Journal of the American Medical Association.

 

Photograph by Ashley Gilbertson /VII.

data saving lives, healthcare, management and leadership, policy, politics, rapid learning health systems

Blumenthal: On the need for the leaders to be IT savy

 

http://www.commonwealthfund.org/publications/blog/2014/jun/of-leaders-and-geeks

Of Leaders and Geeks

 Tuesday, June 24, 2014

David Blumenthal
By David Blumenthal, M.D.
Consider these seemingly unrelated developments:
  1. An IT failure (healthcare.gov) nearly destroys a president’s legacy, while a seeming IT triumph (the National Security Agency’s electronic snooping skills) throws his foreign policy into turmoil.
  2. According to Michael Lewis’ fascinating and scary book, Flash Boys, Wall Street geeks make billions through high-frequency trading, running circles around clueless masters of the universe in charge of America’s biggest banks and hedge funds.
  3. For the second year in a row, the American Medical Association elects a health IT expert as its president.

This could be nothing. But then again, could it be something really big? Could we be witnessing a fundamental change in the requirements for leadership in health and every other sector of society?

We all live with stereotypes and here is one of the most powerful: We have leaders and we have geeks. Leaders change history. They sit atop governments and corporations. They craft strategy, cut deals, rally the troops, and guide humanity into the future. They don’t need to understand technology, because they have geeks.

Geeks sit in cubicles off-site somewhere. They spend their days coding, wiring, and rushing to help impatient leaders whose systems are down. Geeks show up when they’re needed, and go away when they’re not. The technology they manage is like plumbing or electricity. If you don’t like your plumber or electrician, there’s always another in the wings.

Leaders don’t have to manage geeks. They have people who have people who manage geeks.

Like all stereotypes, this one is exaggerated and not wholly accurate, but it makes a point. In health and other areas, leaders sometimes take a kind of perverse pride in their ignorance of information technology and how it works. It’s as though familiarity with IT would damage the aura that qualifies them for the huge responsibilities they seek and enjoy. Of course, they may have content expertise acquired during their rise through the ranks. In health care, it may be training and experience as a health professional and/or academician; in business, it may be marketing or finance; in government, it may be elected office or policy expertise. But almost never is an understanding of information technology considered a vital ingredient in preparing leaders to assume their great responsibilities.

There are exceptions. The leaders of some of the world’s most successful new companies—Microsoft, Google, Apple, Facebook—are or have been technologists.  But they run technology companies. It makes sense that for this industrial sector, real geeks should sit in the CEO’s office.  But for most of the rest of our public and private enterprises, the gap between technology experts and leaders persists.

This may be changing. Recent history suggests that at least for health care leaders—whether in government or the private sector—a deep appreciation for, and even understanding of, information technology may be a vital asset.  How could it be otherwise? In health care, as elsewhere, information is power: not only the power to heal, but also the power to improve quality, efficiency, reliability, safety, and value.  And information technology, acting as a health care organization’s circulatory system, collects, manages, and circulates that information.

Today’s and tomorrow’s successful leaders do not need to be technologists, but they do have to own technology policy and problems in a way few do right now. And they have to incorporate into their inner circles of advisers individuals capable of bridging the historical divide between technology experts and leaders. The alternative could be a future full of healthcare.gov launches, or worse, a continuing failure to take full advantage of the power of information to optimize health system performance.

 

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

Health economics lays down the dirty on doctors… not sure i buy all of it

A couple of suggested reads following a chat with Anthony Carpenter…

Le Grand – Government failure

 

FROM: P132-134 in W.C. Hsiao/Health Policy (32) 1995 125-139.

Hsiao – market failure

While physicians can serve as agents for patients, advising them about needed medical treatments, physicians also provide those treatments and earn their livelihood from them. The dual role of agent and provider creates an imperfect agency relationship, allowing physicians to induce demand for their own services in the interests of profit or professional satisfaction.

[…]

Studies have found that physicians possess the ultimate degree of market power as demonstrated by their ability to price-discriminate [17] and to induce demand for profitable services such as the use of expensive and profitable technology, surgery and drugs [18]. This market failure results in high income for physicians, performance of unnecessary services (which may harm patients), and overuse of expensive technology and drugs.

[…]

Moreover, even in normal circumstances, physicians and hospitals cannot tell patients in advance the price of treatment because of the uncertainty of diagnosis and individual’s recovery rate. Thus, a basic prerequisite of market competition – advance price information-is largely absent in the clinical-service market.

Hospitals also tend to be local monopolies. Because of the large capital investment required to build and equip a hospital, and because of economies of scale, a community may have only one or two hospitals. In an unregulated environment, a hospital could use its monopolistic power to generate excess profit, offer poor-quality services, and acquire expensive and prestige-enhancing technology without regard to cost-effectiveness.

However, price controls are not sufficient to control health costs. International experience shows that providers can increase the volume of services by inducing demand, altering medical practice patterns, and shifting to high-priced drugs, which give higher mark-ups to compensate for falling revenues arising due to price regulations. Developed countries have thus had to regulate both price and quantity. Payment methods based on capitation, total hospital budget, and global budget for physician services have all proven effective in controlling costs and allocating resources. The United Kingdom has adopted the capitation payment method for GPs. Managed-care plans in the United States are also adopting capitation payment. Canada, Germany, and Japan all rely on one form or another of global budgeting to control cost inflation and allocate resources. Their experiences with

global-budget approaches show that these methods are effective in containing cost escalation [20].

Because providers can induce demand, developed nations have found that they have to control the aggregate supply (such as the number of hospital beds, the number of physicians, and distribution of physicians by specialty) in conjunction with other government actions. Otherwise, as Germany found, excess supply creates pressure to increase global budgets. Government has also had to regionalize expensive and complicated services (such as kidney and heart transplants, hip and knee replacements, coronary artery bypass grafts, and the like) because competition for prestige prompts medical centers to acquire the latest technology regardless of cost-benefit.

FROM: P132-134 in W.C. Hsiao/Health Policy (32) 1995 125-139.

data saving lives, health market quality, healthcare, management and leadership, policy, politics, rapid learning health systems

Me in the AFR

And so the slow, arduous public conversation task begins…

PDF: AFR_Healthcare20_BigDataRoundtable_140625

Story & Video: http://www.afr.com/p/business/healthcare2-0/leadership_vacuum_cripples_health_VrDsiSCDYOWXyuvg54QfJN

Leadership vacuum cripples e-health

PUBLISHED: 19 JUN 2014 05:36:14 | UPDATED: 20 JUN 2014 05:18:23

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MARK EGGLETON

Australia continues to struggle with the concept of e-health, with numerous health sector stakeholders equally to blame. This was one of the key messages to come out of the recent Big Data in Healthcare roundtable held by The Australian Financial Review in partnership with GE in Sydney.

Capital Markets CRC principal adviser Dr Paul Nicolarakis suggested part of the problem was Australia lacks a vision for healthcare. He suggested we don’t have someone or a collection of individuals working towards one goal. There are numerous stakeholders across the sector all vying to be the loudest voice, yet not pursuing a common goal.

Chief scientist at The George Institute for Global Health, Professor Anushka Patel said there was no one out there explaining and selling the potential value of big data and e-health or really engaging the government in a productive manner.

“There’s potential to reduce waste and reduce healthcare expenditure without sacrificing quality of care and health outcomes,” Professor Patel said.

“I also think big data could improve our ability to ensure equity, better health outcomes and health access. Those are the two of the big policy messages that need to be conveyed.”

Professor Enrico Coiera, who is the director of the Centre for Health Informatics, said data is already on the move – it just needs to be better linked. He said there is already plenty of data that’s slowly improving quality out there.

“The job is to get that moving around the system. Cheap fees and hospitals sharing information is what we want. Importantly, let’s drop the e from e-health and just improve health services,” Professor Coiera said.

Paul Nicolarakis reiterated that part of the problem was we lack strong, informed, insightful leaders of our health system.

“With all respect to the Australian Medical Association, they are not appointed to be the leaders of the health system. Our health ministers are not health people, they aren’t clinicians or experts in health, and I think, because of these sort of structural limitations, it’s very hard to develop the idea of e-health.

THE TIME IS RIPE FOR CHANGE

 

For the head of the Australian Healthcare and Hospitals Association, Alison Verhoeven, the time is ripe for change right now. She suggested that, with the federal Health Minister Peter Dutton talking about structural reform in the health system, the time is right to really address the big data question as it can help drive efficiency.

Verhoeven said a more streamlined system would see better consumer as well as clinician engagement.

“It’s about better system leadership as well.

“I’d really like to see a more integrated healthcare system generally come out of the structural reforms being discussed at the moment but whether that happens or not is another matter,” she said.

GE Healthcare Solutions managing director Dr David Dembo shares Verhoeven’s cautious view that we’re not going to see any real change in Australia.

“Unfortunately change happens very slowly in health and it happens slowly because free market principles don’t apply and because we don’t have strong leadership.

“We need to have people step up to the plate who are prepared to make brave and considered decisions, particularly around selling a vision and building a culture that gets buy-in from everybody – doctors, consumers and politicians.

“This journey we’re going on to take the ‘e’ out of e-health is the opportunity to de-fragment our health system and you only do that when everybody agrees this is a data science and this is our opportunity for health to behave as a system.”

 

 

The Australian Financial Review

Story: http://www.afr.com/p/business/healthcare2-0/privacy_fears_curb_health_growth_kxxq9sVuxrKDFz6enebgWP

Privacy fears curb e-health’s growth

PUBLISHED: 15 HOURS 46 MINUTES AGO | UPDATE: 14 HOURS 8 MINUTES AGO

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Privacy fears curb e-health’s growth

“We have to be able to sell people a vision about why e-health is important to them,”, says Australian Healthcare and Hospitals Association CEO Alison Verhoeven. Photo: Reuters

MARK EGGLETON

In a twist on the old highwayman demand of “Your money or your life” we finally have an answer when it comes to e-health. Our personal finances win while our health takes a back seat.

Right now most Australians when they want to get a snapshot of their financial situation can go online and find up-to-the-minute information on their bank balance and outstanding debts. We’re pretty comfortable with the level of security afforded our financial details and even happy to give out further details if we’re keen on purchasing goods or services. Unfortunately, we’re a little leery about having our health records available online beyond what’s stored in a computer on our GPs desk.

Security of data was one of the major focuses of the recent Big Data in Healthcare roundtable held byThe Australian Financial Review in partnership with GE in Sydney with most participants agreeing it was an issue.

According to Australian Healthcare and Hospitals Association CEO, Alison Verhoeven, the best way to address people’s privacy concerns is better communication.

“We have to be able to sell people a vision about why e-health is important to them,” she says.

Furthermore, Verhoeven worries that while we continue to argue around the fringes of the debate we’re falling behind as technology moves on.

“The focus of discussion around e-health is on the desktop versions of e-health. We haven’t actually really begun to talk about the mobile versions of e-health so we’re really constructing a system that works on old technology,” Verhoeven says.

Part of the problem with Australia’s roll-out of some form of e-health framework was the personally controlled electronic health record (PCEHR) set up by the last federal government was it was poorly conceived and advertised, with very few Australians opting to ­participate.

OPT OUT, NOT OPT IN

 

Chief scientist at The George Institute for Global Health, Professor Anushka Patel says the best option would have been to give Australians the opportunity to opt out of the PCEHR rather than opt in.

In her experience in health services research it’s often very difficult to get opt-in consent, logistically, and opt-out consent is frequently used.

“Very few people opt out. Even in situations where opt-out can occur later in the course of the investigations very few people opt out. That’s a real test of whether people have real concerns such as privacy. I certainly think opt-out is the way to go,” Professor Patel said.

Director of the Centre for Health Informatics Professor Enrico Coiera says people do have a right to be a little apprehensive about data security and part of the problem is health services, especially government departments, don’t really “have their heads around the issue yet”.

For Paul Nicolarakis, the principal adviser from Capital Markets CMC and former senior adviser to Tanya Plibersek (the previous government’s health minister), the privacy question is an obvious concern. Yet he believes we have communicated the benefits of e-health in the wrong way.

“If e-health is valuable then it’s the same conversation as immunisation. It’s like everyone feels a bit of pain, you’ve got to go get your injections, but there’s value, which is you don’t get sick.

“If we can start framing an e-health record, as immunisation has been so brilliantly framed over the years, then I think people will get it. The analogy runs right through to there even being a kind of herd immunity granted to the population when everyone or most people are on board. The upside for the community is massive, and I don’t think that’s been articulated that well,” ­Nicolarakis says.

Interestingly, the US, which a few years ago was in last place in terms of implementing an e-health strategy, is now considered a leader in terms of ­policy sharpness and ensuring e-health has a positive impact.

US EXAMPLE

 

The US has built the idea of “meaningful use” into the core of their electronic health record technology.

“It’s not talking about whether you have your boxes ticked in terms of what software you’ve got or what computers you have. It asks the question of whether the e-health record has a meaningful impact on patient care,” Nicolarakis says.

Dr Terry Hannan from the University of Tasmania and Launceston Hospital has seen the meaningful impact more connected health and better use of data can have on a number of projects around the world. He was the co-founder of the largest e-health system in the world for managing the AIDS epidemic of 40 million people in Africa.

“We’re now in over 200 countries in the world and we have a massive amount of standardised data for clinical day-to-day care, resource utilisation, research and outcomes. It’s now linked to the mobile health phenomenon and patients are using their own data via a mobile phone as a tool for improving their care.”

Hannan says similar programs have been rolled out in a number of communities in developing countries.

“In Pakistan, we track the multi-drug treatment for tuberculosis right down to the individual house and patient.

We can monitor the food that’s supplied to these impoverished people so they comply with their medication, all recorded on a mobile phone in a country with interrupted connectivity to the internet,” Hannan says.

PREVENTATIVE OPPORTUNITY

 

The roundtable panel agreed the great potential of e-health lies in the preventative health sphere where the use of non-health data such as our nutrition habits could help revolutionise our future health outcomes.

Professor Patel says we could potentially link the quite extensive databases that already exist.

“We already have one for everything that’s available in any supermarket in Australia and a lot of that information was crowd-sourced – people with their mobiles.

“Link that to frequent user, loyalty programs that some of the big supermarkets have and we can look at what people spend at the check-out counter, and you can very accurately predict how levels of obesity are going to change due to the composition of ­people’s diet, their salt intake and more,” she says

“It allows you to target health outcomes at the policy level.”

Unfortunately, this hardly gets mentioned in the more emotive debates around privacy and the supposed infallibility of clinicians.

“Most of the unexplained variation in health research is from people who believe their own clinical insights and experience is of greater value than what might be data driven or might be ­evidence-based,” Patel says.

Verhoeven agrees and says moving our thinking away from anecdote-driven decision-making to data-driven decision-making is a real challenge for clinicians.

Professor Patel says the future starts now, but it requires a change of thinking across the profession.

“It is important this data driven approach to medicine is integral to the training of this current generation of doctors and healthcare professionals otherwise we’re not going to get the ­cultural change down the track.”

 

 

The Australian Financial Review

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The Vitality Institute: Investing In Prevention – A National Imperetive

Vitality absolutely smash it across the board…

  • Investment
  • Leadership
  • Market Creation
  • Developing Health Metrics
  • Everything…!

Must get on to these guys…..

PDF: Vitality_Recommendations2014_Report

PDF: InvestingInPrevention_Slides

Presentation: https://goto.webcasts.com/viewer/event.jsp?ei=1034543 (email: blackfriar@gmail.com)

 

From Forbes: http://www.forbes.com/sites/brucejapsen/2014/06/18/how-corporate-america-could-save-300-billion-by-measuring-health-like-financial-performance/

Bruce Japsen, Contributor

I write about health care and policies from the president’s hometown

How Corporate America Could Save $300 Billion By Measuring Health Like Financial Performance

The U.S. could save more than $300 billion annually if employers adopted strategies that promoted health, prevention of chronic disease and measured progress of “working-age” individuals like they did their financial performance, according to a new report.

The analysis, developed by some well-known public health advocates brought together and funded by The Vitality Institute, said employers could save $217 billion to $303 billion annually, or 5 to 7 percent of total U.S. annual health spending by 2023, by adopting strategies to help Americans head off “non-communicable” diseases like cancer, diabetes, cardiovascular and respiratory issues as well as mental health.

To improve, the report’s authors say companies should be reporting health metrics like BMI and other employee health statuses just like they regularly report earnings and how an increasing number of companies report sustainability. Corporations should be required to integrate health metrics into their annual reporting by 2025, the Vitality Institute said. A link to the entire report and its recommendations is here. 

“Companies should consider the health of their employees as one of their greatest assets,” said Derek Yach, executive director of the Vitality Institute, a New York-based organization funded by South Africa’s largest health insurance company, Discovery Limited.

Those involved in the report say its recommendations come at a time the Affordable Care Act and employers emphasize wellness as a way to improve quality and reduce costs.

“Healthy workers are more productive, resulting in improved financial performance,” Yach said. “We’re calling on corporations to take accountability and start reporting health metrics in their financial and sustainability reports.  We believe this will positively impact the health of both employees and the corporate bottom line.”

The Institute brought together a commission linked here that includes some executives from the health care industry and others who work in academia and business. Commissioners came from Microsoft (MSFT);  the Robert Wood Johnson Foundation; drug and medical device giant Johnson & Johnson (JNJ); health insurer Humana (HUM); and the U.S. Department of Health and Humana Services.

The Vitality Institute said up to 80 percent of non-communicable diseases can be prevented through existing “evidence-based methods” and its report encourages the nation’s policymakers and legislative leaders to increase federal spending on prevention science at least 10 percent by 2017.

“Preventable chronic diseases such as lung cancer, diabetes and heart disease are forcing large numbers of people to exit the workforce prematurely due to their own poor health or to care for sick relatives,” said William Rosenzweig, chair of the Vitality Institute Commission and an executive at Physic Ventures, which invests in health and sustainability projects. “Yet private employers spend less than two percent of their total health budgets on prevention.  This trend will stifle America’s economic growth for decades to come unless health is embraced as a core value in society.”

business, data saving lives, entrepreneurship, healthcare, management and leadership, meaning, policy, politics, startup, technology

Google Ventures – moving medicine out of the dark ages

Duke story about direct monkey brain implants that allow the control of more than two arms.

Great take on dealing with lagging regulation:

“You shouldn’t ignore the laws. But if you worry as an investor about, “Oh, you shouldn’t invest in any personal genomics companies because there’s a lot of regulations that need to be updated.” Well, you won’t do anything innovative.”

So yes, absolutely, the regulations need to catch up with reality. I think as the outcomes of the science with Foundation Medicine, 23andMe, etc., start to become important to people and to patients, people will demand that change. And that’s how it happens.

http://recode.net/2014/06/21/google-ventures-bill-maris-on-moving-medicine-out-of-the-dark-ages/

 

Google Ventures’ Bill Maris on Moving Medicine Out of the Dark Ages

June 21, 2014, 7:00 AM PDT

By James Temple

Google Ventures made health startups a sizable part of its portfolio from the earliest days, even as other investors avoided the space in recent years.

Venture capital funding for the life sciences sector dropped by $5 billion from 2008 to 2012 and was basically flat last year, according to market reports. But the search giant’s venture arm, established in 2009, has steadily plugged money into companies throughout the space, including: 23andMe, Adimab, DNANexus, Doctor on Demand, Foundation Medicine,Flatiron Health, iPierian, One Medical Group, Predilytics, Rani Therapeutics, SynapDx and Transcriptic.

Some of the bets have started to pay off. Foundation Medicine raised $100 million in an initial public offering in 2013. Earlier this year, Bristol-Myers Squibb bought portfolio company iPierian in a deal that could be worth up to $725 million.

The focus on the space at least in part reflects the background of Google Ventures’Managing Partner Bill Maris. He studied neuroscience at Middlebury College and neurobiology at Duke University. In his early career, he was the health care portfolio manager at Swedish investment firm Investor AB.

Maris also took a lead role in the creation of Calico late last year, a Google-backed company focused on delaying aging and the diseases that come with it. (Google has declined to discuss the company, which is run by Genentech Chairman Arthur Levinson.)

“Medicine needs to come out of the dark ages now.”

Bill Maris, managing partner, Google Ventures

Google Ventures generally isn’t taking the old biotech route, betting on companies somewhere along the winding path of developing drugs that may — but probably won’t — someday earn Food and Drug Administration approval. Rather, the firm is focused on companies leveraging the increasingly powerful capacities of computer science, including big data, cloud processing and genomic sequencing, to improve diagnostics or treatments.

In the second part of my two-part interview, which has been edited for space and clarity, Maris discusses the promise of these tools for medicine as well as what’s still standing in the way.

Re/code: Looking through your health-care investments, there’s 23andMe, DNA Nexus, Foundation Medicine, Flatiron. To the degree there’s a common theme, it seems these are all big data plays, using a lot of information and smart algorithms to make advancements in medical research or hit upon more effective treatments. Is that part of your investment philosophy?

Maris: I used to be a health-care investor a long time ago in the public markets. One thing I learned that we tried to apply here is that investing in small molecules, trying to invest in the next treatment, there’s an element of gambling to that.

I’m glad that people started those companies and I’m glad that they have people who specialize in investing in them. But that’s not our specialty, because you have to build a portfolio to make a success overall.

What we try to put into our practice is “invest in what we know,” which is where health care meets technology. In some sense, almost all companies these days need to be big data companies.

Bill Maris, managing director, Google Ventures

Especially when you get around genomics or, like Flatiron, looking for insights across vast amounts of oncology data. These are by definition big data companies that couldn’t have existed 10 or 15 years ago.

Take Foundation Medicine. The tools didn’t exist to actually genotype quickly the way that we can today, and in 10 years it will be even more advanced. So by necessity the companies we’re investing in are in that space, because that’s the forefront.

Clinicians treating patients based on “if you present with these symptoms, I’m going to treat you based on the knowledge in my head?” Those days are either disappearing or will soon disappear, I hope. We can get much better outcomes from people if we understand the genetic basis of the exact cancer that they have, what interventions might be most effective against it, what’s worked in the past and what hasn’t. I think that’s where the future of health care is.

So yes, lots of these are big data companies, in that sense. But that’s a catchphrase, they’re more than that. They’re data-informed companies that are trying to build businesses that are commercially important and, in this case, relevant to patients. That means they’ll get better outcomes, you’ll live longer and be healthier.

Medicine needs to come out of the Dark Ages now.

There is a unique challenge when it comes to data and medicine. Either you have a lot of information that is stored away in paper filing cabinets in doctors’ offices, or you’ve got companies that did studies decades ago that might be of use but they’re either not digitized or they’re holding on to them as intellectual property. So while there’s this great potential, it’s actually really hard to get at it. Can you talk a bit about what needs to happen technologically?

Of course it’s difficult. If it were easy it would be done by now, there would be nothing remarkable about what Nat [Turner] and Zach [Weinberg] are doing at Flatiron. The fact that it’s difficult is what makes it something an entrepreneur needs to tackle — and this isn’t unique, right?

All the information in the world has been pretty dispersed, but Google’s mission has been to organize it and make it universally accessible. That’s kind of a crazy mission and they’re doing okay at it. It takes people with a vision to say, “We’re going to try to organize this and make it accessible to people.” When we do those things, good things will result from that.

Maybe it takes a generation, because doctors will start using the system. Or maybe it just takes one big push, where we’re just going to go into clinicians’ offices and help them get all the data organized and put into electronic formats. Once you’ve done it one time you can gain an infinite number of insights to help your patients, so there’s a good motivation to do that.

Organizing healthcare information is a daunting task, but it is not an impossible task. We’ve had people walk on the moon. This is a lot more doable.

I want to ask about 23andMe. We’ve seen a handful of companies in that space that have closed or haven’t gone anywhere, and 23andMe obviously hit a big wall with the FDA last year.

I don’t know what you’re talking about.

Yeah, I read it somewhere. But that was a big part of their business, can you talk about what their ongoing prospects are and what direction they could steer in?

Yeah, as I understand it, the heredity product is still available and we see big businesses being built there, like Ancestry.com and others.

At the same time, their vision is bigger than that. They’re at an impasse with the FDA right now, but no one has thrown up their hands. Communication is ongoing, they’re trying to work that out, we’re dedicated to trying to resolve that roadblock. And we think it’s a product that is of value to people, so they can look at and understand their own genomic information.

I think the company’s prospects are great, I’ve known [co-founder] Anne [Wojcicki] for almost 20 years now, and she’s nothing if not focused, dedicated and motivated. She’s a believer in this. I think the company has been a little bit ahead of its time.

It’s inevitable that everyone will eventually be genetically sequenced because it’s going to be really important to their health care, to understanding their future and what they’re at risk for. If you believe that, then you believe that there’s probably a big business to be built here because someone has to deliver that information.

So we have a lot of faith in the team.

Taking that case — and given that health care and medical research is moving in this digital direction — do you think there are some regulatory shifts that need to take place?

I think the laws need to catch up with science and reality, and the law is never good at that. It’s always slow.

I mean, look at the patent office. I just saw a patent that Smucker’s has for a peanut butter and jelly sandwich. It’s sort of crazy.

Look at Uber and its regulatory challenges, taxi and limousine commissions trying to stop Uber. When you sit with my job — which is a really fun job to do, kind of a judge at a science fair — it’s really important to look at the technology and how it might benefit people, and not worry about the bureaucracies that might try to impede that.

At the end of the day, what always happens is, the right products for society and the people get out there.

You shouldn’t ignore the laws. But if you worry as an investor about, “Oh, you shouldn’t invest in any personal genomics companies because there’s a lot of regulations that need to be updated.” Well, you won’t do anything innovative.

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By , Jun 20, 2014, 7:30 AM PDT

 

So yes, absolutely, the regulations need to catch up with reality. I think as the outcomes of the science with Foundation Medicine, 23andMe, etc., start to become important to people and to patients, people will demand that change. And that’s how it happens.

You studied neuroscience and neurobiology. What are some exciting developments you’re seeing in your own area?

I also think we’re just coming out of these Dark Ages in neuroscience. The forefront of neuroscience is (he points to parts of his head), “Well, this is the learning area, this is memory, this is where the right arm is controlled.” That’s not really how the brain works, it’s this cloud-based understanding.

I forget which neuroscientist said this, but you essentially have a Jennifer Aniston neuron. There are certain pathways in your brain that remember who that is. The more you fill up your brain with those things, the more neurons get used up.

So we’re getting closer to a point, and there are some folks at MIT working on this and other places as well, to really understanding the wiring of the brain. What makes it a whole, what causes consciousness. It’s not just that these cloudy regions all talk to each other.

You can’t do anything without a map. Until you can diagnose something you can never cure it, you can’t understand it. It’s hard to get from here to there without a map. So the first thing to do is to build a model.

When you can map an entire human brain, then you can really understand how it all works.

We don’t even know if everything gets recorded in your brain and your brain is just really good at controlling noise, where it’s just filtering out a bunch of things that you don’t need to think about because you’d just be overloaded. So there are these fundamental questions of neuroscience we just now have the tools to understand.

It’s so far behind, it’s so underfunded, in a way. We as a people and a country spend a lot of money on a lot of things. But we all walk around with this thing in our head and we have no understanding of how it actually works.

Machine-brain interfaces are a way to understand that. There’s a guy at Duke named Miguel Nicolelis, who I worked with and who comes out here every once in a while. He does work where he implants electrodes into brains and he’s now got monkeys who can move cursors on a screen [with virtual arms] and they get a reward of orange juice. Then he thought, “Well, why is the monkey just limited to one [virtual arm]? Maybe I could teach them to move three at once, or four.”

What we are learning from that is, well, we have two legs and two arms, but your brain is actually capable of operating four or six of them if you had them. There’s so much potential.

Here’s what the monkey saw in that experiment:

health market quality, healthcare, policy

Lap banding not as neat as it sounds with a 20% revision rate…

 

https://www.mja.com.au/insight/2014/22/high-lap-band-surgery-revision

High lap band surgery revision

Nicole MacKee
Monday, 23 June, 2014
High lap band surgery revision

AN Australian pioneer of bariatric surgery says laparoscopic adjustable gastric banding remains preferable to gastric bypass as a primary bariatric procedure, despite findings that almost 20% of patients will require revisional surgery within 3 years.

Professor Paul O’Brien, emeritus director of Monash University’s Centre for Obesity Research and Education, said he would like the revision rate to be lower, but the procedure was “still good health care”.

“You can’t expect to treat a chronic disease — a lifetime disease — with a single treatment and then walk away and never have to worry about it again”, he said.

An Australian analysis of Medicare data for more than 6000 patients undergoing laparoscopic adjustable gastric band (LAGB) surgery in 2005–2006, published in JAMA Surgery, found that the rate of revisional surgery was 18.9 events per 100 patients, comprising 11.4 intra-abdominal and 7.5 subcutaneous surgical procedures. (1)

JAMA Surgery also published the findings of a French retrospective review of 831 patients who had a primary gastric bypass and 177 patients who had a secondary gastric bypass after failed LAGB. The researchers found similar rates of major adverse outcomes in both groups — 7.8% in the primary procedure group and 8.5% in the secondary procedure group. (2)

A commentary accompanying  the French study said that a higher rate of revisions required after LAGB compared with Roux-en-Y gastric bypass was driving an increase in the number of conversions from LAGB to other interventions, including sleeve gastrectomy, gastric bypass and duodenal switch. (3)

Professor O’Brien said the French study made the important point that there was no difference in safety for a patient having a revision of a gastric bypass or a patient having a primary gastric bypass. However, he said, in Australia it was far more common for LAGB patients requiring revision to have the problem with the band fixed rather than having more invasive gastric bypass.

“Every operation will have a revisional surgery rate and it becomes a surgical decision as to whether you revise to fix it up … or you go to something else”, he said.

The Australian analysis found that conversions to other bariatric procedures (1.3 events per 100 patients) and LAGB reversals (1.9 events per 100 patients) were uncommon here.

Professor O’Brien said the French study showed that for primary gastric bypass as well as secondary gastric bypass after failed adjustable gastric banding, there were some serious risks.

“You’ve got a [hospital] length of stay of 5–6 days, you’ve got a leak rate of 12 patients [n = 1008], you have a total of five deaths. You’ve got rate of abdominal reoperation within 30 days of 6%. This is serious stuff”, he said.

LAGB revision could be a day procedure with “a high probability of being very safe and, in our experience, a high probability of as good a weight loss as you get with the other procedures”, said Professor O’Brien, citing research, on which he was lead author, which found that 47% excess weight loss was maintained 15 years postprocedure, regardless of whether revision surgery was required. (4)

Professor John Dixon, head of clinical obesity research at Baker IDI Heart and Diabetes Institute, said there had been “tremendous advances” in the safety of bariatric surgery in recent years, but the reoperation rates for all procedures remained too high.

“All [bariatric procedures] are associated with what we can say is a high reoperation rate that we would like to reduce so that it minimises people’s risk of having to have multiple operations”, he said.

However, he said, while the reoperation rate was “a nuisance”, it should not detract from the overall improvement to health and quality of life provided by these procedures.

“We have to recognise that these are surgical procedures that are essential for many of our patients, they produce a total change in their life”, he said.

Professor Dixon advised GPs to keep a close eye on patients who have had bariatric surgery for any gastrointestinal symptoms and for nutritional deficiencies, which could also result from the procedures.

“If you’re seeing symptoms that worry you … always involve a bariatric surgeon. There have been some major issues when patients have gone to a general surgeon or a gastroenterologist for symptoms that are related to complications of their bariatric surgery”, he said.

 

1. JAMA Surg 2014; Online 18 June 
2. JAMA Surg 2014; Online 18 June 
3. JAMA Surg 2014; Online 18 June 
4. Ann Surg 2013; 257: 87-94

business, complex adaptive systems, entrepreneurship, health market quality, healthcare, policy, politics, quotes & aphorisms

Relman Obit: the medical-industrial complex

RelmanOnHealthcare

http://t.co/g9LnZnM5ta

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Dr. Arnold Relman, Medical Editor and Health System Critic, Dies at 91

By 

Dr. Arnold S. Relman in 1979 at The New England Journal of Medicine. He led it for 23 years.Associated Press
Dr. Arnold S. Relman, who abandoned the study of philosophy to rise to the top of the medical profession as a researcher, administrator and longtime editor of The New England Journal of Medicine, which became a platform for his early and influential attacks on the profit-driven health care system, died at his home in Cambridge, Mass., on Tuesday, his 91st birthday.

His wife, Dr. Marcia Angell, said the cause wasmelanoma.

Dr. Relman and Dr. Angell filled top editorial posts at the journal for almost a quarter-century, becoming “American medicine’s royal couple,” as the physician and journalist Abigail Zuger wrote in The New York Times in 2012.

The couple shared a George Polk Award, one of journalism’s highest prizes, for an article in 2002 in The New Republic that documented how drug companies invest far more in advertising and lobbying than in research and development.

His extended critique of the medical system was just one facet of a long and accomplished career. Dr. Relman was president of the American Federation for Clinical Research, the American Society of Clinical Investigation and the Association of American Physicians — the only person to hold all three positions. He taught and did research at Boston University, the University of Pennsylvania, Oxford and Harvard, where he was professor emeritus of medicine and social medicine.

Early in his career, he did pioneering research on kidney function.

He was also editor of The Journal of Clinical Investigation, a bible in its field, and he wrote hundreds of articles, for both professional journals and general-interest publications. Days before he died, Dr. Relman received the galleys of his final article, a review of a book on health care spending for The New York Review of Books, to which he was a frequent contributor.

In a provocative essay in the New England journal on Oct. 23, 1980, Dr. Relman, the editor in chief, issued the clarion call that would resound through his career, assailing the American health care system as caring more about making money than curing the sick. He called it a “new medical-industrial complex” — a deliberate analogy to President Dwight D. Eisenhower’s warning about a “military-industrial complex.”

His targets were not the old-line drug companies and medical-equipment suppliers, but rather a new generation of health care and medical services — profit-driven hospitals and nursing homes, diagnostic laboratories, home-care services, kidney dialysis centers and other businesses that made up a multibillion-dollar industry.

“The private health care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need,” he wrote. In an editorial, The Times said he had “raised a timely warning.”

In 2012, asked how his prediction had turned out, Dr. Relman said medical profiteering had become even worse than he could have imagined.

His prescription was a single taxpayer-supported insurance system, likeMedicare, to replace hundreds of private, high-overhead insurance companies, which he called “parasites.” To control costs, he advocated that doctors be paid a salary rather than a fee for each service performed.

Dr. Relman recognized that his recommendations for repairing the health care system might be politically impossible, but he insisted that it was imperative to keep trying. Though he said he was glad that the health care law signed by President Obama in 2010 enabled more people to get insurance, he saw the legislation as a partial reform at best.

The health care system, he said, was in need of a more aggressive solution to fundamental problems, which he had discussed, somewhat philosophically, in an interview with Technology Review in 1989.

“Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there’s only one way to diagnose or treat an illness,” he told the review. “In reality, that’s not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive.”

Dr. Relman edited The New England Journal of Medicine from 1977 to 1991. Founded in 1812, it is the oldest continuously published medical journal in the world, reaching more than 600,000 readers a week. Dr. Angell was the editor in 1999 and 2000.

When he took the journal’s helm, interest in health news was booming, and newspapers and magazines competed to be first in reporting new developments. One policy he instituted was to ask general-interest publications not to disclose a forthcoming article in advance, a request almost always honored, albeit sometimes grudgingly.

He also began requiring authors to disclose any financial arrangements that could affect their judgment in writing about the medical field, including consultancies and stock ownership.

Dr. Relman and Dr. Angell met when she was a third-year student and he was a professor at Boston University School of Medicine. They published a paper on kidney disease together in The New England Journal of Medicine, then did not see each other for years.

After he became the journal’s editor, he asked her to come on board as an editor, which she did, abandoning her career as a pathologist. They began living together in 1994 — both were divorced by then — and married in 2009.

They became the ultimate medical power couple, not least because they were gatekeepers for one of the world’s most prestigious medical journals. Their outspoken views further distinguished them.

“Some have dismissed the pair as medical Don Quixotes, comically deluded figures tilting at benign features of the landscape,” Dr. Zuger wrote in The Times. “Others consider them first responders in what has become a battle for the soul of American medicine.”

Arnold Seymour Relman was born on June 17, 1923, in Queens (in an elevator, according to Dr. Angell) and grew up in the Far Rockaway neighborhood. His father was a businessman and avid reader who inspired his son’s love of philosophy. His mother nicknamed him Buddy, and friends called him Bud the rest of his life.

He skipped grades in school and graduated at 19 from Cornell with a degree in philosophy, but he chose not to pursue the field because it “seemed sort of too arcane,” his wife said. He earned a medical degree from the Columbia University College of Physicians and Surgeons at 22. His first marriage was to Harriet M. Vitkin.

In addition to Dr. Angell, he is survived by his sons, David and John, and a daughter, Margaret R. Batten, all from his first marriage; his stepdaughters, Dr. Lara Goitein and Elizabeth Goitein; six granddaughters; and four stepgrandsons.

Last June, Dr. Relman fell down a flight of stairs and cracked his skull, broke three vertebrae in his neck and broke more bones in his face. When he reached the emergency room, surgeons cut his neck to connect a breathing tube. His heart stopped three times.

“Technically, I died,” he told The Boston Globe.

He went on to write an article about his experience for The New York Review of Books, offering the unusual perspective of both a patient and a doctor.

“It’s both good and bad to be a doctor and to be old and sick,” he told The Globe.

“You learn to make the most of it,” he added. “Schopenhauer, the German philosopher, said life is slow death. Doctors learn to accept that as part of life. Although we consider death to be our enemy, it’s something we know very well, and that we deal with all the time, and we know that we are no different. My body is just another body.”

Correction: June 23, 2014 
An earlier version of this obituary misstated where Dr. Relman and his wife, Dr. Marcia Angell, met. They met when she was a student and he was a professor at Boston University School of Medicine, not Harvard Medical School. Because of an editing error, the earlier version also misstated the dates of Dr. Relman’s tenure as editor of The New England Journal of Medicine. He held the post from 1977 to 1991, not from 1977 to 2000. (Dr. Angell was editor in 1999 and 2000.)

A version of this article appears in print on June 22, 2014, on page A23 of the New York edition with the headline: Dr. Arnold Relman, 91, Outspoken Medical Editor, Dies. Order Reprints|Today’s Paper|Subscribe

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BBC Start The Week: Thinking about new forms of Government

Compelling discussion about new thinking about, and forms of government…

http://www.bbc.co.uk/podcasts/series/stw

Tristram Hunt, Adrian Wooldridge, Charu Lata Hogg and Anjan Sundaram

Mon, 9 Jun 14

Duration:
42 mins

Tom Sutcliffe discusses whether Western states have anything to learn from countries like China and Singapore. Adrian Wooldridge argues that many governments have become bloated and there’s a global race to reinvent the state. In the past Britain was at the forefront of exporting ideas on how to run a country, as the Labour MP Tristram Hunt explains in his book on the legacy of empire. Charu Lata Hogg from Chatham House looks at the challenges to democracy in Thailand where the country is in political turmoil, and the journalist Anjan Sundaram spent a year in The Congo during the violent 2006 elections, and looks at day-to-day life in a failing state.