By John Ballard
For reasons I can't understand, this morning's reading has more good links than I can cover one at a time. Any of the following would make a good blog post, but I simply don't have time. Scan the list and pick what catches your interest. A couple of technical / legal topics are not for everyone. But most of these strike me as important.
?Cancer 101: Male breast cancer
Dr. Salwitz, blogging oncologist, provides crib notes for a statistically rare condition, listing risk factors and other minutiae. I am personally aware of only one instance of male breast cancer among al the people I know, but for him it is not a trivial topic. Here's a snip but there is more at the link.
There are several risk factors for male breast cancer. In men with Jewish background, there is an increased risk if there is breast cancer in the family. Men that carry the breast cancer gene (BRCA1 or BCA2) have up to a 15% lifetime risk (as apposed to 0.5% without). Other genetic abnormalities such as Klinefelter�s, Cowden�s and Lynch Syndromes increase the chance a man will get breast cancer. Men that have breast enlargement (gynecomastia), which is often related to medications, are more likely to be affected. Testicular problems such as recurrent infections, injury and undescended testes may increase the cancer risk, probably by changing hormone levels. It appears that cirrhosis increases male breast neoplasms. Men who have had breast cancer in one breast, are more likely to get cancer in the opposite breast.
?NCCI's second day - state v fed regulation
Joe Paduda, our go-to guy for all managed care information (workers comp angle) is attending the National Council on Compensation Insurance annual conference.
From the moment I thought about universal health care my first impulse as a cafeteria manager was to see it as a long-awaited resolution to one of the most expensive "controllable" costs of operating any business -- workers compensation for job related illnesses and injuries. Silly me. I actually thought the whole point was making people well and getting them back to work. No way. It has a little to do with health care, but the serious money has to do with insurance costs. (One euphemism is risk management but the costs include a good many fixed expenses having nothing to do with risk. Liability, labor laws and the infrastructure expenses of the insurance industry also have to be paid for -- sales bonuses, advertising, executive compensation, and shareholder dividends and profits come to mind.) But I digress as usual...
Anyway, this little insight about state and federal regulations is germaine to the national discussion about universal health care. With the fate of ACA still in the balance and one of the main GOP talking points being that foolishness about purchasing insurance across state lines, this caught my eye. (My emphasis here and below.)
While McCarty et al may decry the interference of federal authorities in the insurance process, payers may be less negative after considering the additional costs inherent in state-specific regulation. According to a report in Insurance Journal earlier this week,
"Tyler Leverty, a professor of finance in the Tippie College of Business, says that the expenses associated with meeting regulations in every state in which an insurance company does business drive up compliance costs by 26 percent when compared to companies that are regulated by only one state.
"These high regulatory compliance costs reduce the technical efficiency of firms, deter firms from operating in additional states, and increase the price of insurance," says Leverty."
These next four links from The Health Care Blog have little in common other than that site, but all four drive home important subjects. I have noticed that the last few months The Health Care Blog seems to have multiplied its output exponentially. I haven't seen anything about that from Matthews Holt, blogmaster, but either he's making more money or getting more contacts yielding a raft of good posts.
?Making Privacy Policies Not Suck
Aza Raskin, former head of user experience at Mozilla Labs and creative lead for Firefox, now runs Massive Health, a startup that aims to help people take control of their health. This post originally appeared at his blog. In this brief post he advocates the use of icons and graphics to streamline a layman's understanding of privacy issues. I'll get there some day, I guess, but meantime I'm still skipping the mouse-print and clicking the little boxes that follow.
This is a quickie but I'm including it mostly for the fun factor in the comments thread. The subject of privacy is a legitimate ongoing concern, not only for medical records but everything in life, it seems. I'm not getting into that quagmire other than saying that I gave up on meaningful privacy expectations long ago. I'm not careless, but I'm not obsessive, getting overcome by righteous indignation if someone wants to see ID. And I quit using a screen name on the Internet a couple years ago. John Ballard is my real name (along with a few thousand other John Ballards).
Now go look at the exchange in the comments.
?Zen and the Art of Not Thinking Magically
Dr, Lamberts lists and elaborates on imaginary thinking traps into which we can easily fall.
- No news is good news
- The doctor will think I am stupid
- Doctors don�t want to be questioned
- Standard care is the right care.
- My doctors talk to each other
- My doctor has accurate records
- I will be notified when things are due
- Hospitals care 9. More is better
- New is better
He makes all of these traps easy to grasp, but I really like #8 about caring hospitals.
The commercials boast of how local hospitals are �there for you when you need them most,� and �your advocate for your health.� This is horse hockey. The people in the hospital may be caring and kind. The doctors, nurses, and even administrators may want you to be healthy. But the hospital is a business which requires people to be sick and have lots of procedures done to be profitable. Most health care dollars are spent in hospitals, and many times those dollars do no good to the patient. I�ve seen end-stage cancer patients get heart catheterization, people with dementia spend weeks in the ICU, and countless other procedures are done with no benefit (other than income to the hospital).
Don�t be fooled. Your goal is to stay healthy and stay out of the hospital; your doing so is bad for the business of hospitals.
Boy, this one has been a long time coming. I've been railing for years about the difference between health care and risk management, reflected in the different missions of insurance companies and health care providers. We have been spoon-fed from infancy the idea that health care comes from insurance when it always comes from a medical provider. The mission of insurance is not managing health but setting the boundaries of what is or is not "affordable" (whatever the hell that means).
- The end of medical underwriting in the ACA, combined with other demographic, regulatory, and economic factors, made health insurers� business model increasingly untenable.
- These changes will not go away, one way or another, no matter what the Supreme Court does, no matter who is elected in November. These changes are directly tied not just to legislation but to underlying demographic and economic realities
- This is not a terrible thing. �We got pulled through the crucible against our will and have been reshaped because of it,� he said. �For most of what has already been implemented, it has been a pretty good thing.�
- Health insurers are unlikely to disappear. But their primary role in the future will be using new technologies to help accountable health systems serve their customers and drive out costs � and the health systems, not the health insurers, will increasingly be the face, the brand, of that improvement. �We can use technology to make it easier for the consumer. Convenience is the new word for quality.�
I'm not worried about the insurance industry. They have many other products to offer and plenty of customers eager to buy, happy to pay experts to assess the fine points of risk management. Auto collision and liability, home theft, fire and flood, life insurance (term, universal and all the so-called "investment" variables in between), the list in endless...
And as long as company-sponsored group plans are offered the TPA market will always be out there. But the days of treating essential health care as a market commodity are slowly but surely (one can hope) coming to an end.
Danielle Ofri is the author of three books, including �Medicine in Translation: Journeys with My Patients.� She is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review.
This is a book report and recommendation to read God's Hotel A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine by Victoria Sweet.
Dr. Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.
Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, �slow medicine,� as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.
Sweet realizes that the inefficiencies of this old-fashioned hospital � from the doctors who had time to fully research their patients� complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients � were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.
This is the sort of report that makes me want more time in my life for recreational reading. But when you're already in the choir, it's sometimes tedious to sit through the same old hymns, no matter how much you may have liked them growing up. **Sigh**
As usual, here is a link to American Book Exchange, my favorite book source. (Sorry, Amazon. Eat your heart out.)
?NwHIN: Government Governance of Governances
Reader advisory -- this is geek city stuff. Procede at your own risk.
Margalit Gur-Arie is a specialist in health information technology. She's really smart. I keep up with her for the same reason I follow any other expert I hope never to need in my life.
When political types toss a piece of legislation into the burearucratic fire (think campers discarding a lit cigarette) they leave it up to technocrats to see it doesn't cause a forest fire. This is where the Margalit Gur-Aries of the world come in.
We're all familiar with the Good, Bad and Ugly metrics. To these three she appends a great new category she calls The Exaquisite. (I'm not gonna try to splain all the acronyms. Readers who get it will already know and the rest of us can just admire what she says in the same way we are happy the washing machine comes with an electrical schematic on the back so the repairman won't get lost.)
After what seems like an eternity, ONC officially recognizes that de-identified information can be rather easily re-identified and that those who happen to own the hardware infrastructure where people�s medical records are stored do not have an inherent right of ownership to those records. I would very much like to see ONC extend this regulation to every HIT vendor, not just those specializing in exchange of information, since if it is pertinent to NVEs, it must be also pertinent to EHRs, HIEs, ancillary software vendors and, yes, pharmacy software vendors. I am not naive enough to believe that CTE [S-6] will survive the rule making process, but for the moment, the detailed description of the dangers inherent in the wholesale of patient data is reason for celebration.
(==>Incidentally, I think this is related to the privacy issues mentioned above.)
This link-filled post by Naomi Freundlich is the red meat of this morning's menu. I'm not going to parse what she says because in this instance the reader MUST go to the link prepared to read it carefully and ingest what she says. This is too important to skip.
The imminent expansion and also specificity of the data pool as more and more information is recorded and dumped into large computerized repositories begs for a new kind of analysis that identifies �hot-spots� and outliers that resist the trends; local areas, single hospitals, particular members of ethnic or racial populations and other demographic subsets that defy the odds when it comes to national health outcomes or usage of medical services.
We�re already seeing this in the realm of Medicare payment data; the Dartmouth Atlas has for years been identifying regional variations in the cost of care in different parts of the country and even between neighboring towns. Now, as the first step toward linking reimbursement to efficient care, the Center for Medicare and Medicaid Services has released new findings from its own study of hospital and post-discharge cost variation. According to coverage in Kaiser Health News, �the figures show wide variance among hospitals around the country, even ones just a few miles apart. In Los Angeles, for example, the average patient admitted to Los Angeles Community Hospital cost Medicare nearly $24,644 during the stay and in the month afterward, 37 percent above the national median. Across town, according to the data, an essentially similar patient admitted to Ronald Reagan UCLA Medical Center cost Medicare $17,628, or 2 percent below the median�
This is about two subjects: dollar costs and social phenomena. Figuring out how these two variables puzzle together an how best to measure and control them is more challenging than finding a cure for disease. As I read this my mind wanders back to the book report above. And even though I have not read the book, I already know that the links between costs and results are tenuous and difficult to manage at best.
A line from an old spiritual comes back to me this Sunday morning...
If religion were a thing that money could buy,
the rich would live and the poor would die.