November 23rd, 2009

The medical home is reform without objections, so far

Posted by Dana Blankenhorn @ 10:13 am

Categories: Aging, Ethics, Finance, General, Government, Home Health Care, Hospital IT, IT Management, Internet, Medical IT, Medical Office IT, Medical Records, Wellness

Tags: Team, Patient, Health Care, Home, Doctors, Team Management, Management, Dana Blankenhorn

There is one type of health reform that, so far, has received little publicity and no political objections.

It’s called the medical home. (Picture from the American Academy of Family Physicians.)

Physicians have been talking up the concept since the 1960s, and at its heart it is pretty simple. Charge for wellness and create a team, headed by a physician, that can deliver it.

When people like Larry Green, who heads the American Board of Family Medicine, talk about moving toward a “blended payment” model he’s advocating for this team approach to care.

Many doctors’ groups support the medical home, but getting from here to there is not easy. Doctors are basically being asked to create a new business, with a new set of employees, and to do this they need start-up capital.

The AAFP magazine Family Practice Management published an article last month with 10 suggested steps for getting that capital.

These start with using existing medical codes to generate more revenue from each patient visit, hiring more nurses and medical assistants, then using these people to increase the number of patients you “see” each day. Wash, rinse, repeat.

If this sounds like gaming the system to generate revenue, it reads like this to me, too. But this revenue has a purpose. The article suggests that capital go into an Electronic Health Record (EHR) system, a “patient portal” through which customers access health data, and links to other helpful electronic resources.

One idea of the $19.2 billion HITECH stimulus cash is that it helps doctors pay for these computer resources so they don’t need to game the system to get the money. But they still have to build scaled businesses.

Only after doctors have their office and systems right should they focus on high-cost patients, the article continues. A lot of alligators need to be slain before you drain this swamp.

From the patient point of view, you’re going to be given a lot more control over your care, you’re going to have a lot more appointments with people other than the doctor, but you’re going to get more face time with people trained to help you.

It’s that face time that can end disputes like the present one over pap smears and other tests. You will have people you can discuss these issues with, people who have access to your medical records, people who will have the time to listen to you as well as talk.

Now that you know the good news, here is the bad news:

1. The financial success of a medical home is based on nagging. You get the data, you get access to the people, but money is only saved when you take the advice.
2. It takes money and business transformation to get from here to there. Running a team takes money and organization. Either doctors become businessmen or go to work for people who are. Either they buy and build systems they need or they associate with others who have them.

A health policy based on the medical home is going to be a lot more intrusive than the present fee-for-service model. The team will know if you smoke, how much you drink, what you eat, even what you’re likely to die of, based on a whole lot of data.

If the medical home is to save money, and lives, that team will need power to enforce what’s good for you. It could come from an adjusted insurance rating, based on your observed lifestyle, with the higher fee going to your medical home.

Or the medical home needs the power to force you out for non-compliance.

The medical home, in the end, offers the promise of lower costs and personal attention, in exchange for your willingness to be bound by your doctor’s advice on what’s good for you.

Do you still like the medical home?

November 16th, 2009

Niacin best for raising good cholesterol

Posted by Dana Blankenhorn @ 5:42 am

Categories: Aging, Consumer Information, Drugs, Finance, General, Home Health Care, Medical Equipment, Research, Wellness

Tags: Cholesterol, Dana Blankenhorn

Want more of that good HDL cholesterol?

(Picture from Costco.com.)

Try a timed-release niacin, and be skeptical if your doctor gives the sales pitch for Zetia or Vytorin.

The authority for this is a study dubbed ARBITER-6, which was stopped suddenly this summer, with the study’s authors insisting safety had nothing to do with it.

It was a question of efficacy.

The results, described in the New England Journal of Medicine, make clear that niacin does better at the main job, keeping arteries open.

“The use of extended-release niacin causes a significant regression of carotid intima–media thickness when combined with a statin and that niacin is superior to ezetimibe.”

Ezetimibe is the generic name for the active ingredient in Zetia, while Vytorin combines the same drug with a generic statin, simvastatin.

This does not mean ezetimibe is worthless. It works. It just doesn’t work as well as niacin.

This has important implications for anyone who, like me, has a family history of hypertension and high cholesterol. But if you want to save some serious money, look further.

The ARBITER-6 study compared ezetimibe with Niaspan, a drug form of timed-release niacin. But you can get similar dosages, for a lot less, with a supplement containing the same stuff. I use something called Slo-Niacin.

On most insurance plans you’ll pay $10/month for a generic statin and $30/month for Niaspan, or $30 for Zetia, “saving” $10 by using Vytorin (which contains the statin).

But Costco offers 150 Slo-Niacins for about $10, so even if you double your dosage to 1 gram (as many doctors recommend, taking one in the morning and one at night to prevent flushing), that’s $14/month for simvastatin and niacin, or $30/month for Vytorin.

Last time I got checked out, my combination of simvastatin and 1 gram of SloNiacin per day was working like a champ. Total cholesterol under 150 and a ratio of bad to good that had my doctor putting exclamation marks on my chart.

The paragraphs above, combined with the results of ARBITER-6, represent the heart of comparative effectiveness, and the way we old-timers can interpret those results to stay healthy for less.

As health IT begins collecting hundreds of millions of health records over the next several years studies like this will become easier to do, and they will be more accurate, given the larger number of records being studied.

But this is bad news for drug-makers. You not only have to prove safety, not only prove that your drug does what it claims, not only prove you’re better than a placebo, but you now have to prove you’re better than alternatives before you’re going to get the big money.

Bad for drug companies, good for patients. That’s what comparative effectiveness studies are all about.

November 12th, 2009

What Intel wants in health care

Posted by Dana Blankenhorn @ 6:10 am

Categories: Aging, Assistive Technology, Gadgets, General, Home Health Care, Home Health Care Equipment, Medical Equipment, Rehabilitation

Tags: Health Care, Intel Corp., Venturebeat, Vertical Industries, Benefits, Healthcare, Sales Strategy, Human Resources, Sales, Dana Blankenhorn

Our Tom Foremski is shocked, shocked that Intel is launching a camera that reads.

What’s going on, he asks? Intel is terrible at consumer products. (Picture from Intel.)

But the Intel Digital Health Group is as serious as a heart attack, and the Intel Reader is part of it. The device is actually a specialized computer, combining a camera, optical character recognition, and a voice chip.

I have a stake in this, because my daughter is dyslexic and my mother blind. I appreciate the hard work that went into this. The $1,500 price tag is off-putting, but Moore’s Law tells me that in time it should come down.

And therein hangs our tale.

Intel produces what is now a commodity. It is the dominant supplier of chips but margins are thin. It needs higher margins to thrive.

Health care offers those higher margins. Health care and assistive technologies offer humongous margins because production runs are often small and sales channels thin. Venturebeat says the Intel Reader, for instance, will be going to CTL, Don Johnston, GTSI, Howard Technology Solutions and Human Ware.

None are exactly Best Buy. These are specialty resellers. Johnston, for instance, specializes in technology for dyslexic and autistic kids.

Still, these are growing markets. The Intel Health Guide, for instance, is aimed at the business of aging in place. There are 76 million of us baby boomers and we’re not getting any younger — ka-ching.

And let’s look again at the Reader. Products for the blind, for the autistic, and for the dyslexic are traditionally seen as separate markets. Here we have one product that addresses all of them. That means more sales which can drive down costs. In this business that’s an innovation.

So there is potential here for the perfect marketing storm. A company that can drive down costs enters a market with enormous margins. It can get fat on slimmer margins than those it finds in the market. As it drives down prices it expands the market — I might get that Reader for my daughter when it comes in at $400 (and in time it will).

This can truly be a win-win-win. The assistive technology and health care markets want lower prices, which Intel can deliver. Lower prices will expand the reach of things like aging in place technologies and readers for the dyslexic. Intel can build a highly-profitable business that in time delivers top line growth as well as bottom line growth.

Sure, there are specialty channels to figure out. Sure there are new marketing skills here Intel has not yet mastered. But price can cover that up while those skills are learned. This is the lesson Japanese and Chinese producers have been teaching us for decades.

And if they want to offer a review unit, I’ve got some good testers coming in for Christmas.

November 4th, 2009

How fast can remote monitoring move?

Posted by Dana Blankenhorn @ 12:07 pm

Categories: Aging, Always On, Assistive Technology, General, Government, Home Health Care, Home Health Care Equipment, Internet, Medical Equipment

Tags: Monitoring, Standards, Approval, MedApps, Quality, Business Operations, Dana Blankenhorn

Remote medical monitoring, the use of sensors and networks to detect changes in patients and deliver alerts to caregivers, has been growing throughout this century. (Picture from Abledata.)

This week’s approval of an Alcatel-Lucent TeleHealth Manager by the FDA is just the latest 510(c) approval in a long line.

• RODA got approval for remote heart monitoring in 2002.
• St. Jude’s Medical has been getting remote monitors approved since 2004.
• Medic4All got approval on its VMS-01 telemedicine system in 2006.
• Medtronic has had heart monitors that can be pinged remotely for over three years.
• MedApps has been selling a remote diabetes monitoring system over the counter since 2007.
• ExpressMD got approval for its Electronic House Call system in April.

Not everything is rosy in this business, and not all the fault lies with government. Insurers are reluctant to reimburse, which makes no sense since these systems save enormous amounts of money. BIOTRONIK’s remote heart monitors have been approved to replace doctors’ visits.

Where Intel (and its new partner GE) can provide a service to the whole industry is by helping to streamline these approvals, from both industry and the FDA.

Electronics are insanely reliable. The links available between devices, base stations, and caregivers, via the Internet, are also improving thanks to Moore’s Law. You can even get remote health monitoring through WiFi.

What the industry needs to get past the analysts’ hockey stick graphs are standards. Technical standards, payment standards, approval standards. This is no longer rocket science, it’s not experimental.

Make it part of the technology mainstream, let remote monitoring benefit from Moore’s Law economics, and medicine will be truly transformed, in Internet time.

October 29th, 2009

Diabetes can be kept at bay

Posted by Dana Blankenhorn @ 6:23 am

Categories: Aging, Consumer Information, Drugs, Ethics, General, Home Health Care, Research, Wellness

Tags: Diabetes, Dana Blankenhorn

Want to save billions of dollars on America’s health bill?

Cut the rate at which people come down with diabetes.

(The site from which this illustration was taken, at Doctorsecrets.com, has a great page on diabetes, explaining the cause, the symptoms, effects and treatment in plain English.)

Right now 24 million Americans have diabetes and another 57 million are in a “pre-diabetic” stage. The latter group’s risk can be cut in half, over 10 years, with self-discipline on diet and exercise, along with a generic drug called metformin.

The latest study, published in The Lancet’s Online First journal, was a follow-up to the Diabetes Prevention Program, an earlier study which showed diet and exercise reduced onset of the disease 34% over four years, and metformin cut it by 18%, compared with rates using a sugar pill.

In the follow-up people who had been on the placebo or metformin were offered the lifestyle program, since it was proven to have benefits.

While some media reports pushed the lifestyle angle exclusively, the study made clear that those who exercised and ate right but also took the drug maintained their weight loss, while those who made the changes without it gained some weight back.

On average, losing weight alone delayed the onset of diabetes by four years, drug therapy alone reduced it by two years. Those over 60 did even better with lifestyle changes than younger patients.

The American Diabetes Association maintains an online test to assess your risks of Type II diabetes.

While it is fun to say “it’s their fault,” meaning the patients (and it is to an extent), the refusal by society to treat a chronic condition like diabetes runs against medical ethics. It’s not going to happen.

Preventable deaths in the tens of millions to suit your ideology are not in the cards.

Prevention costs a lot less than treatment, and much of the savings expected from health reform is based on studies like this which prove that prevention works.

October 5th, 2009

A Nobel links aging, cancer, evolution and politics

Posted by Dana Blankenhorn @ 10:33 am

Categories: Aging, Consumer Information, General, Research, genetics

Tags: DNA, Cancer, Szostak, Telemorase, Biotechnology, Healthcare, Dana Blankenhorn

The 2009 Nobel Prize in Medicine went to three American researchers whose work on the ends of DNA and the enzyme controlling them link the disparate subjects of cancer, aging and evolution.

Oh, and there’s a dose of politics.

Elizabeth Blackburn and Jack Szostak were colleagues in the early 1980s, and Carol Greider was a Blackburn grad student, when Greider discovered the enzyme telemorase in 1984. Greider thus becomes famous for winning a science Nobel at the relatively “young” age of 48.

Szostak has since worked on the evolutionary aspects of this discovery, seeking explanations for how chemistry became biology in Earth’s earliest days.

Blackburn and Greidner worked on how telemorase builds telomeres at the end of DNA, redundant genes that protect the underlying DNA structure like a plastic cap on a twisted electrical connection. Telemorase declines as we age, but becomes abundant in cancer.

The practical result might be a cancer vaccine which attacks cells that produce telemorase, turning off the cancer process while allowing normal aging to continue.

We promised some politics, and it comes from Blackburn (above, from the Nobel Prize Web site).

Appointed to the President’s Council on Bioethics in 2001, she was fired in 2004, but she did not go quietly. Instead she blew the whistle on the Administration’s “political distortion” of biomedical science, detailing it all with another member, Janet Rowley, at PLoS Biology.

Oh, and before my fellow Americans haul out their USA chants, Blackburn was born in Australia and Szostak in England.

September 23rd, 2009

The problem with health care is costs and you

Posted by Dana Blankenhorn @ 7:40 am

Categories: Aging, Consumer Information, General, Government, Home Health Care, Research, U.S., Wellness

Tags: Health Care, Health Care System, Vertical Industries, Benefits, Healthcare, Human Resources, Dana Blankenhorn

Demographer Samuel Preston of the University of Pennsylvania has crunched the numbers on life and death and finds no big problems with the U.S. health system.

Except, that is, for the cost. And you. (Illustration from the blog of Home Base Holidays.)

Preston looked at numbers on life expectancy and death rates, going back decades, and found Americans don’t fare that badly compared with Europeans, and on some measures (like cancer screenings) we do quite well.

Any gap in life expectancy, he writes, is due to deaths in middle age. And most of those are due to smoking — U.S. smoking rates were once among the highest in the world. If we also lost some weight we would live as long as people anywhere.

The results can, and will, be spun from both sides of the partisan divide:

• The health care system is not broken.
• The health care system is inefficient and pays too little attention to wellness issues.

Conservatives will note that lack of access to care does not seem to be resulting in shorter life spans. Liberals will argue that current reform efforts are geared specifically to making the system more efficient and focusing on issues like weight and smoking that kill millions.

Taking responsibility for preventing disease, not just treating it, will lead to cries of nanny state from some. But Nannyism works.

August 31st, 2009

Blackie asks the hard questions on health care

Posted by Dana Blankenhorn @ 8:50 am

Categories: Aging, Ethics, Finance, General, Government, Home Health Care, U.S.

Tags: Vet, Health Care, Blackie, Death Panel, Social Security, Healthcare, Cyberthreats, Operational Accounting, Personal Finance, Government

Meet Blackie.

She’s 15, a mutt whom we think is partly Tibetan terrier.

(Here she is this morning, coming in from a bathroom break. I am not much of a photographer.)

Blackie has had a hard life. Her first owner abused her. When we got her from a shelter, at what we were told was 18 months of age, she suffered so badly from heart worms it required two treatments to get her right.

This was when my kids were very small. They named her. Guess why?

Anyway, Blackie is nearing the end of her run on this planet. She is far beyond any age that might be achieved by a wild dog.

She’s blind. She’s deaf. She’s senile. She spends most of her days on a dog bed in the corner of our front room, sleeping. We notice her when she asks to go out for a bathroom break. Often, these days, she doesn’t remember to ask and does it wherever she is.

This led us to a vet visit. Today’s vets can keep pets alive as well as their human counterparts can keep grandma going.

The vet prescribed Anipryl. Its active ingredient is Seligline, sometimes prescribed for Parkinson’s and depression in human beings.

It also costs over $80 per month, even from Canada. Those kids I mentioned are going to college, and I’m not feeling too good myself.

When my own bills got up that high, I worked to find generic substitutes and off-the-shelf replacements for my problems, eventually cutting my pharmacy bill in half (not counting the cost of supplements).

“Time to convene an Obama death panel,” I joked.

But the question is serious, and becoming more so. We have many ways of extending life today that did not exist before. When Social Security began people lived to be 68. My father-in-law, on the other hand, was 88 when he passed, and his funeral was filled with friends who were even older than that.

For good dogs like Blackie the answer is usually made by economics. It’s the American way.

But what happens when it’s your mother, your spouse, or you whose life hangs in the balance? Now we’re talking of much bigger numbers, I know. One-fourth of Medicare costs come in the last year of life.

Talking about what to do now, while you’re still healthy and lucid, can make an enormous difference, not just in terms of costs but your quality of life at the end.

This is what critics call the “death panel.” It has little to do with money, although it does save. It has everything to do with human dignity. It’s a valuable service, one worth paying for.

Now if you’ll excuse me I’m going to convene Blackie’s death panel.

August 24th, 2009

Condemning what the market does worse

Posted by Dana Blankenhorn @ 5:00 am

Categories: Aging, Ethics, Finance, General, Government, Insurance IT, Payment Processing, Research, U.S.

Tags: Bank, Patient, Insurance Company, Doctor, Insurance, Government, Financial Services, Business Operations, Corporate Insurance, Dana Blankenhorn

The most cynical part of the current health care debate is how industry advocates have turned their current practices into controversial, even evil-sounding threats against citizens.

(Picture of Fox News report from MediaMatters.)

Take the idea that “the government will force you to give up your bank numbers.” I complained about post-care bills in a recent post and got several private e-mails from doctors saying they had a simple solution to the problem.

They took the patients’ bank numbers before giving any care.

Works great for the doctor. Once the insurance company is done you just bill the patient’s credit card or debit card for what is left. But the patient is given no prior notice of how much is being charged. What if the doctor overdrafts their account?

Thus the fear of what government might do is more than matched by what industry is already doing.

This is especially true with comparative effectiveness. None of the bills that have passed committee mandate the use of best practices derived from data. Yet there was Sen. Coburn on TV sanctimoniously intoning that the Obama plan would “get between a patient and her doctor” using just such research.

Trouble is such research is moving forward, and insurance companies do plan to use it to drive costs down. That’s what HMOs were all about, mandating less-expensive care, only without numbers to back it up. With the numbers you have no appeal.

What Coburn is complaining about is what industry is doing and plans to do more of.

Or take the nonsense about “death panels.” This refers to a provision that Medicare cover end-of-life counseling. A House bill describes the services to be performed. Betsy McCaughey, who started the death panel slander, tried to sell it to Jon Stewart of The Daily Show recently by reading the bill.

A recent AARP survey in Massachusetts shows this is something seniors want, something they need, and something they are not yet getting. Some 89% said they wanted honest answers from doctors before the end, while they are still lucid, but only 17% said they were getting that service.

Then there’s the question of end-of-life care itself. The House bill gives seniors choices on how, when and where to get this care. Insurers, meanwhile, are entering exclusive agreements with hospice providers, telling you where you will die to maximize their profit.

Few deny the Obama Administration has mangled the health care debate. On my personal blog I have compared this to how the Bush Administration handled Hurricane Katrina.

But if the result is that voters see everything Republicans taught them to fear, only done privately and for twice the price, all the PR in the world won’t smooth things over.

August 20th, 2009

A modest proposal to fix the primary care shortage

Posted by Dana Blankenhorn @ 11:24 am

Categories: Aging, Ethics, Finance, General, U.S., Wellness, state government

Tags: Shortage, Vertical Industries, Benefits, Healthcare, Strategy, Human Resources, Management, Dana Blankenhorn

Whether a health reform plan passes or not, the U.S. has and will continue to have a big, big shortage of primary care doctors.

(That’s Dr. Joseph Mambu, on the left, from a recent CBS Reports story on this subject.)

A New England Journal of Medicine article says this is one of the big factors driving up costs. When patients see a lot of specialists it costs more. When they can’t develop a relationship with a primary care giver they can lose the self-discipline needed for wellness.

Every health reform plan — whether Republican or Democratic, whether from interest groups or insurance companies — emphasizes the need for more primary care.

Trouble is there is less-and-less of it available.

This is already having a big impact in Massachusetts, which reformed its health system to mandate insurance coverage three years ago. CBS reports that even insured patients there are often unable to find a primary care doctor.

Meanwhile there is a 3,200 doctor shortage in community health centers nationwide, so what you might think is a back-up does not exist.

If the fee for service business model is not going to change, the problem is just going to get worse.
The American Academy of Family Physicians is estimating a shortage of 70,000 primary care doctors in 10 years. There are currently about 100,000.

The American College of Physicians has offered some good ideas. One idea, changing the rules o n Medicare reimbursements to favor primary care, has already started a fight among lobbyists.

But there’s a second suggestion, based on an existing federal program, the National Health Service Corps, which can forgive up to $50,000 in medical student loans when doctors choose to offer primary care in underserved areas.

Fact is, the entire U.S. is about to become an underserved area. So expand the program. Take up the payments on any doctor choosing primary care so long as that doctor stays in the field.

A medical school degree can cost up to $200,000, while primary care physicians can earn as little as $120,000, less than one-fourth what a surgeon can earn. Do the math.

If you want more doctors in primary care, change the math. Don’t forgive the loans all at once. Forgive the payments, or subsidize them, for each year of primary care through the term of the loans. It is in effect a big raise for new doctors.

Doctors who are currently practicing primary care may complain, but maybe we can throw a bone to them, too. How about this? Fellowships, sabbaticals and vacations, an awards program paid for by insurance companies and drug companies, targeting physicians in primary care.

Give out awards, tell their stories of courage and sacrifice in the local press. Make them heroes. The good ones are. More private scholarships for primary care should also be available.

When I suggested just giving primary care physicians raises and cutting the pay of specialists I got a ton of pushback from readers. Meanwhile the problem has gotten worse.

Anyone have a problem with this?