Everybody’s Talking about the Future of Health Care

January 18, 2008 at 12:31 pm · Filed under Uncategorized, Insurance, Industry Sector, Public Purchasers, Health Plan/Payer CEOs, Policy Makers, Business of Health, Medical Tourism, Retail healthcare, Electronic Medical Records, Research, Alternative Medicine

I don’t know if you’ve noticed but as we move into 2008 there’s a glut of papers, reports and predictions about what is going to happen in health care. Some have such a definitive tone, it makes you wonder if any have read Nassim Nicholas Taleb’s, The Black Swan, which engenders in the reader a humble appreciation and respect for role of high impact, improbable events in social affairs.

Anyway, I’ve taken the time to look through some of these pronouncements. Many are rehashes of the what I would call “more of the same” prognostications, others find us at various tipping points — unsustainability being a key concept here — in health care and forecast some, often vague, deep changes to come. Below are some of the bits and pieces of these various offerings of the future that caught my eye.

• Expect large institutions to make significant IT investments; RHIOs will still struggle with architecture and governance models; EMRs creep closer to reality, and health plans will continue to implement consumer-directed vendor partnerships. (Forrester)
• Doctors are using the Internet far more than their national averages, using email, obtaining professional information from online journals, attending courses and conferences, receiving professional updates and performing professional, administrative functions. . . In essence, in the short space of time that the Internet has been easily accessible through the Web, doctors have harnessed its power in both their personal and professional lives. All indications are that they will continue to do so. ( Masters)
• Two areas that are going to get a lot of play in the next year or two. There are a number of products in the telemedicine space that use IT not as a database or workflow tool, but as a telecommunication and management system, teleradiology is one prime example. The other is interoperable home-monitoring devices. There’s good value with keeping people out of nursing homes, and it’s getting a lot of attention right now from doctors, hospitals and health plans. (Brailer)
• Don’t see much of a business case for health 2.0 technologies, although personal health records as a concept has some validity, particularly as a service provided by health plans and employers. Still in a wait-and-see mode on PHRs. (Brailer)
• Medicare’s Hospital Insurance (HI) Trust Fund is already expected to pay out more in hospital benefits this year than it receives in taxes and other dedicated revenues. The growing annual deficit is projected to exhaust HI reserves in 2019. (Friedman)
• For the first time, a safe, effective and reversible hormonal male contraceptive appears to be within reach. Several formulations are expected to become commercially available within the near future. Men may soon have the options of a daily pill to be taken orally, a patch or gel to be applied to the skin, an injection given every three months or an implant placed under the skin every 12 months. (Schieszer)
• U.S. health care costs are growing at 8 percent per year, an unsustainable rate that will be forcing every employer to make a crossroads decision in the next 12 to 36 months: either continue to provide health care benefits to employees and become very aggressive about controlling expenses or exit the insurance market completely and let employees fend for themselves. (Deloite)
• Physician-hospital tensions will increase. Employer-health plan tensions will increase. The non-conventional provider movement (complementary and alternative medicine) will be pitted against the conventional. Off-shore resources will compete against high-cost domestics. The under-insureds will compete with employers for funding and services. Biologics developers will attempt to fend off traditional pharma to capture the high ground in diagnostics and therapeutics. Tension, anxiety, and turf battles for success will heat up, but so, too, will opportunities. (Deloite)
• In an environment where employers and consumers are demanding more for less, medical tourism, telemedicine, and other innovative disruptions offer attractive options for people who require expensive surgery and procedures but do not want to be limited by their health care insurance policies. (Deloite)
• Significant change is unlikely prior to 2010 and is apt to be gradual thereafter. Although urgency is still the operative word, the players involved have a healthy respect for the complexity of the problem and the runaway costs that will result if they get it wrong. Even if some changes emerge in the first year of the new administration, implementation would take at least a year. Bigger changes would probably follow, being phased in starting in 2011. (Booz Allen)
• A surge in the number of retail clinics will force states, payers, and policy makers to think about the right model for the delivery of primary care. (PWC)
• The market for individual health insurance could take off. (PWC)
• We envision the proliferation of “health infomediaries” (HIs) who help consumers navigate the insurance, channel and service options in care delivery. HIs will become a fixture in the landscape for both the well and the chronically ill, and for a much broader socioeconomic segment of the population. (IBM)
• The combination of the push for universal coverage, the erosion of employer-based insurance and the aging population is expected to drive this continued shift to individual and government-based coverage. (IBM)

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Do We Need “Chief Experience Officers” in PHM?

January 15, 2008 at 12:50 pm · Filed under Hospital and Health System CEOs, Retail healthcare, Population health management, Alternative Medicine

The concept of having a “chief experience officer” is starting to catch on in healthcare organizations (HCOs), witness the organizations such as the Cleveland Clinic that have adopted the idea. These “CEOs” do not usually sit at the same table or work in the same “C-Suite” as the chief executive officer, chief financial officer, etc. but the notion of having a person at a high level in the organization responsible for customer experiences has at least some champions. [A. Cirillo “Embracing the Philosophy of the Chief Experience Officer (Even If Your Organization Won’t” HealthLeadersMedia.com Jan 8, 2008]

The idea of having a single person “in charge” of customers’ experiences is founded on the reality that customer experience is becoming the major, often the sole competitive distinction available to many HCOs, where consumers tend to think all are of equal quality in terms of health services. The recognition is also growing that the “patient experience” includes more than what happens inside the walls between admission and discharge in a hospital, or arrival and departure from an ambulatory care facility.

Recognition that “customers” include more than patients, such as family members, especially physicians who refer or admit patients to the hospital or ambulatory facility, and payers peaked long ago, while focus on consumers is growing. And no one in most HCOs is in a position to manage the entire customer experience for any of these customers, though programs for physicians and payers are often more formally organized, with clear accountability held by somebody. [In my last position as Chief Marketing/Strategy Officer, I shared responsibility for payer relations with the CFO.]

But does having a chief experience officer make sense for HCOs that are engaged in the population health management (PHM) business? Clearly, it makes sense for such organizations to have someone accountable for relations with the employers, commercial insurers or government agencies the PHM HCO deals with, both winning new customers and keeping current ones. But does it make sense for the other “customers”, namely the individual participants in the PHM interventions that are the main source of benefit to employer, insurer, or government clients?

To answer such a question requires first a definition and description of what the “experience” is for participants, as does the same question with respect to clients. In most cases, the experience that champions of the chief experience officer are dealing with involves the processes of interaction and transactions between the seller and the buyer. But in PHM, a far more important consideration for clients will be the outcomes of such interactions and transactions, not so much the process that is involved. And even with participants, the outcomes to individuals may play a major role in determining how many participate in the first place, and how many remain participating as long as they yield benefit for themselves and the payer that is footing the bill.

This does not mean that the process elements in interactions and transactions are ignored. Any inconvenient, upsetting, disrespectful, or otherwise unpleasant interactions or transactions between the PHM HCO and its clients or participants would seriously jeopardize the relationship. But it is more often the question of what clients and participants get out of this relationship, versus the characteristics and process elements of the relationship, that make the biggest difference.

For these “new” CEOs to be successful in PHM HCOs, they will primarily have to become fully familiar with what kinds of outcomes both categories of customers expect and would welcome from their process experiences. Not only must these process experiences be satisfying in their own right, they must lead to early indications of progress, if nor success in PHM initiatives and investments. How much clients and participants have to invest, for example, in money, time, and effort, compared to how much benefit they perceive themselves as gaining, will greatly determine what they think of the experience.

PHM HCOs would be wise to initiate their own “early warning” systems to monitor what is happening as a result of their PHM efforts – how many participants show changes in: 1) knowledge/attitudes toward the health challenge each is working on; 2) behaviors that will lead the kinds of health status changes desired, or avoid the changes feared; 3) health status indicators and biometrics that reflect progress and success; and 4) what kinds of reduced use/expense for sickness care (insurers) plus workers compensation and disability expense, worker productivity and performance (employers) has been noted.

The early warning indicators can not only give clients and participants confidence that positive changes are happening, or negative ones not happening, but serve to clearly show the connection between the PHM tactics and activities and the intermediate as well as final results and economic benefit that results. It will enable PHM providers to not only describe what benefits have arisen for both types of customers, but to make a strong case that they arose specifically in response to the PHM intervention or strategy involved, rather than by chance or due to some other cause.

The new CEO in PHM will have to become or already be expert in measuring in addition to achieving the results that clients and participants are looking for. With participants, this will usually involve some objective biometrics, and some subjective perceptions, with both playing a major role in affecting satisfaction and perseverance. With clients, it will usually involve a combination of “hard” objective data from the client’s own operational databases or records, as well as new measures or estimates of productivity/performance impact on employees.

These estimates may become increasingly difficult to tie to PHM elements and measured progress, but when they occur at the same time as, and in a way that is closely correlated with early indicators, the estimates will likely be more readily accepted and deemed credible by clients. Letting any supplier measure the success of its own efforts will always generate some skepticism, but if there is clear evidence for the connection between the process experiences of participants, and their estimated as well as measured results, and a strong link between both hard and soft results, the measurement experience itself is likely to be more satisfying to clients and participants alike.

In the long run, this new CEO must also include the “E” of evidence, since unlike sickness care where recovery and rehabilitation have well-established measurement techniques, the process of tracking outcomes in PHM is in its early development phase, as far as soft data on workforce productivity and performance. Fortunately, this soft data is not only easily translatable into financial benefit measures for clients, but into personal health/life benefits for participants, through well-tested health/life quality metrics. And if chief evidence officer as well as experience, these new CEOs may easily prove their worth to their own organizations, and end up joining their peers in the “C-Suite” based on their proven importance and value.

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The Profit Motive and the Placebo Effect

November 29, 2007 at 2:14 pm · Filed under Policy Makers, Research, Alternative Medicine

The “placebo effect”– i.e. the extent to which a person’s belief in the efficacy of a substance or therapy influences both the physiological and psychological effects thereof – is mainly familiar because of its use in clinical trials. Rigorous science often requires triple-blind studies, where the patients receiving treatment, the providers giving it, and the analysts evaluating it are not “biased” by knowledge of whether or not the treatment is a placebo, i.e. inert substance or sham treatment.

But there have been increasing arguments against thinking of the placebo effect as merely a “false” result. It clearly demonstrates the “mind-body” effect, i.e. the ability of the mind to influence the body’s responses, which accounts for both the negative and positive effects of stress, as well as the positive placebo and negative “nocebo” effects of treatment (where belief that the treatment will do harm produces harm even when the treatment is inert).

Many have argued that the placebo effect, and the nocebo effect for that matter, are both reflections of “enlisting the mind” in the pursuit of healing. Given the ability of this effect to add to as well as detract from the effects of substances and therapies, the effect, when positive, should include the total mind-body response to either, rather than discounting the effect as merely “humoring” patients into believing they are getting treatment when they really need none.

Since the placebo effect is often as much as or even above 50% of patient response noted, the acceptance or rejection of the effect can make a huge difference to the measured efficacy of a given treatment. In a recent book on the positive as well as negative effects of the mind on the body, its author made a strong case for recognizing the importance and value of the mind-body connection, which has been demonstrated in terms of objective physiological responses through the hypothalamus-pituitary-adrenal glands connection. [E. Sternberg The Balance Within: The Science Connecting Health and Emotions W.H. Freeman 2001]

The placebo effect seems to be particularly strong with respect to pain perceptions by people being treated – with almost anything. Since pain is primarily a subjective perception, rather than an objective metric, people who believe in the efficacy of a drug, herb, or therapy often report as much relief from the placebo as from what is supposed to be an “active” intervention. Sham acupuncture has yielded as much pain reduction as the real thing, for example.

The trouble is that the placebo effect can also be the foundation for immense profits by manufacturers and retailers of substances, and providers of therapies, that have no physiological effects at all, that may be dangerous to patients in either or both of two serious ways. They may cause damage, by being inherently inimical to health – or they may prevent or delay people from seeking and getting truly effective alternatives. They may even cause people to avoid or negatively affect what are proven treatments if people “tar them with the same brush” because of their similarity to unproven or proven-to-be-useless/harmful alternatives.

The general system of homeopathy, for example, has been under attack in the U.K. [B. Goldacre “The End of Homeopathy?” The Guardian Nov 16, 2007 (www.badscience.net)] People still swear by its remedies, because they say homeopathic pills make them feel better. But what if the entire impact of homeopathic medicine is “in the mind”, i.e. the placebo effect? A review of 110 homeopathic and 110 matched conventional medicine trials were compared, with both finding that smaller and lower-quality trials tended to find more benefit than did larger and higher quality, but the overall findings were compatible with the notion that homeopathic clinical effects were due to the placebo effect. [A. Shang, et al. “Are the Clinical Effects of Homeopathy Placebo Effects? The Lancet 366 2005 726-732]

In a recent series of stories, the major newspaper where I live describes a wide range of medical devices being manufactured, sold, and used as “energy” treatments. These machines relied on light, radio, electricity, or electromagnetic forces to “cure” diseases as serious as cancer. While such forces have been proven to have positive effects in a number of medical applications, the machines described in the reports had no demonstrable physiological effect, and certainly did not eliminate the conditions that their users claimed would be cured by them.

In most cases, these devices were used by untrained laypersons, though some physicians, chiropractors, and other health professionals, and at least one hospital also used them. [C. Willmsen & M. Berens “Miracle Machines: The 21st Century Snake Oil” Seattle Times Nov 18, 2007 A1, A10-13; “Public Never Warned About Dangerous Devices” Nov 19, 2007 A1, A8; and “A Patient’s Plea: Please God, No More” Nov 20, 2007 A1, A10] One example involved drawing a patient’s blood, treating it with “photo luminescence” light waves (ultraviolet light), then injecting the treated blood back into the patient. Infections at the injection site occurred, but cures did not. The provider was arrested for practicing medicine without a license, while the patient died the day after treatment. While claiming to be a naturopathic physician, the provider had no training, merely a degree from an unaccredited “diploma mill”.

Another device claimed to cure AIDS, cancer, and other life-threatening conditions with electromagnetic waves, and was being used in five states, including Washington, despite the foundation for its efficacy that “…goes beyond human knowledge” according to its inventor. It got around FDA regulations by claiming it was only being used in “clinical trials”, though providers profited from its use, which was not allowed in such trials. Machines had been sold to physicians, chiropractors, acupuncturists , naturopaths, and massage therapists, as well as people with no training at all, and used for desperately ill patients who feared or had already experiences severe side effects from conventional treatment of cancer, heart disease, ulcers, etc.

An out-of-work former mathematics instructor built a radiofrequency wave machine claimed to diagnose and treat everything from allergies to cancer, was forced by the FDA to leave the US, and now operates from Hungary. He has apparently sold over 10,000 of his devices in the U.S. alone. The idea of electric, light, sound, radio and microwaves being used to treat disease is over 100 years old, and has many proven applications, but probably far more unproven ones, with many dangerous, such as the use of electricity or electromagnetic waves in patients with implanted pacemakers, or simply dangerous machines.

Thanks to the placebo effect, almost any machine, nostrum, herb, or therapy may easily find dozens, hundreds, even thousands of patients who report being cured, or at least having pain diminished or disappeared. And these can be powerful testimonials in media advertising or word-of-mouth, viral and “buzz” marketing. Moreover, the placebo effects are real in many cases, though rarely as reliable or complete as truly efficacious alternatives. And given the profit motive, that can drive both professional clinicians and laypeople to purchase and use such machines, as well as sell them to patients, there are strong financial motivations, as well as gullibility that can drive widespread use.

Americans have not only the most expensive healthcare system in the world, but one of the most promising for quacks and charlatans, as well as misguided, well-meaning practitioners and marketers. The FDA has been criticized for years, charged with inadequate and biased regulation of medical treatments and prescription drugs. It has done far worse in the case of unproven (even as to causing harm) alternatives to these, and thousands of people suffer as a result.

At a minimum people who rely on the placebo effect alone are wasting their money where it could be better spent elsewhere, and at worst, they are delaying or avoiding proven alternatives, and dying as a result. The placebo effect is certainly valuable for those who experience it, but when there are alternatives with proven records for positive clinical effect as well, it a dangerous basis for patient choice, and an inadequate basis for generating profits.

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Speaking of CAM and Science – A New Example

September 26, 2007 at 10:50 pm · Filed under Hospital and Health System CEOs, Sickness care, Treatments and Therapies, Research, Alternative Medicine

It has often struck me as a writer, that once I initiate research into a given subject, complementary and alternative medicine (CAM) most recently (see my posting of Sep 24), I almost always run into a new story on that subject, often in a matter of days.  This time it was: C. Johnson “Study: Acupuncture Works for Back Pain”, Washington Post Sep 24, 2007.

The article is an example of both scientific and economic reasons to consider at least the specific CAM treatment involved, namely acupuncture.  Analysis by German researchers indicated that acupuncture works significantly better than conventional medications and other traditional Western treatments.  Over 1100 patients were randomly assigned to 1) acupuncture; 2) sham acupuncture, or 3) conventional therapy.  In the acupuncture group, 47% of patients improved, compared to only 27% in the conventional group.

One of the particularly interesting findings from this study was that sham acupuncture, i.e. where the treatment is “faked” by not inserting the needles as deeply as acupuncture requires, achieved almost as good results as the real thing, with 44% of patients getting the sham version improved.  While Dr. James  Young of Rush University Medical Center, who was involved in the research, says that we don’t know precisely why acupuncture works, and often treats his own patients that way, it is clear that it does work.

When dealing with pain, the patient often wills improvement, by believing there will be an effect, or where the sham treatment creates such a belief.  This “placebo effect” is particularly strong in pain management, and if it occurs with sham treatment, it makes sense to use it as well.  Apparently, in this research, at least, the conventional medical treatment did not produce nearly as great a placebo effect, or else its objective medical effect was so low that even with its placebo effect, improvement was still significantly less than for either sham or true acupuncture.

Dr. Heinz Endres of Ruhr University Bochum, in Bochum, Germany, reported in an e-mail that “patients experiences not only reduced pain intensity, but also reported improvements in the disability that often results from back pain, and therefore in their quality of life.”  He noted that these findings are in line with a theory that pain signals to the brain can be blocked by competing stimuli, such as the needles used in both forms of acupuncture.

It could be, as Dr. Brian Berman at the University of Maryland’s center for complementary medicine suggested, that acupuncture changes the way the brain processes pain signals, or by releasing natural painkillers in the body.  If this is the case, then there is a logical physiological, as well as psychological reason for the reported success.

The “conventional” treatment includes traditional prescription painkillers, injections, physical therapy, massage, heat therapy, or other treatments, with all patients in the study receiving about ten sessions lasting a half-hour each.  Many include both massage and heat therapy in the CAM category, so even when these were included, the acupuncture as a specific therapy appears to work better, though no results specific to these therapies alone were reported.

Because CAM is such a “loose” category of solutions, and because there are so many different specific therapies and therapists that may offer and deliver treatments, this finding cannot be seen as proof that CAM, in general, works – either this treatment for all problems and all patients, or even for all patients with this problem.  As has been demonstrated many times already, people’s genetic differences often create vastly different levels and types of response to traditional medications and treatments, so it should not be a surprise if the same is true for CAM in general, and for acupuncture treatment of back pain in particular.

Of course, to employers or insurers who are looking for the best and least expensive way to manage workers’ or covered members’ back pain, these findings may provide both a scientific and an economic reason to not only accept acupuncture for back pain, but even to recommend it over conventional treatment.  In the spirit of competition, we should look forward to seeing conventional medicine fight back, perhaps by identifying one particular treatment that does better than acupuncture did in this case.  The more we have rigorous science applied to questions of what works, as contrasted to the sophistry of both politics and the market, the better we will all be in the long run.

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