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Sunday, January 24, 2016

Financials bubble through the ages

Tulip Bubble

South Sea Island Bubble

Image result for Tulip bubble

Home mortgage bubble

And from the BBC news...

college-bubble c c

Coproduction in health care

I have been introduced to an interesting concept, that of co-production. I came upon this concept when I read an article published in BMJ  Quality and Safety. (Link) It is actually such an intuitive concept that it is hard to imagine why it did not occur to me and everyone else previously. I guess that is just how ideas are.

In manufacturing, those who produce goods such as cars or consumables do not directly rely on those use consume and use those products to produce them. The end users may influence the characteristics of the products but they play little or no role in product manufacture. Consumers do not play a substantial role in the quality of the final product, whether that be automobiles or chicken pot pies.

The service industry is different. Victor Fuchs noted in 1968 that the new service economy was different from the old manufacturing economy in that the producers and consumers of services worked together to create value. Later Alfred Toffler described the next generation of consumers which he referred to as "prosumers", linking the previously separated function of production and consumption to maximize consumer value and minimize producer cost.

For example, one might hire a financial professional to help with retirement planning. No matter how good the advice of the professional, the final product depends upon the consumer. If the consumer does not follow the advice and put away money for the future, the final product will be substandard, no matter how good the advice. Similarly, if one gives your tax professional the wrong data,  the final product of the tax return will not be up to snuff. Figure¬†2

This concept is also very appropriate for many aspects health care delivery. For patients who present with a diagnostic problem, if they are not capable or willing to provide accurate or complete histories or reviews of systems, they are much less likely to receive accurate diagnoses. For patients who undergo surgery or other interventions who are then discharged home, if they are not willing or capable of following care instructions (or have not been appropriately educated), the outcomes of the interventions are much less likely to be favorable. For patients with chronic disorders where most of the care happens at home, their contributions and buy in may be most essential to optimal outcomes.

However, the co-production involves not just a given provider and a given patient, but teams of providers and other teams which may include patients, their families, and perhaps other patients.

The current payment system is really incompatible with the co-production model. Furthermore, the proposed incentive changes are still predicated on the assumption that outcomes are based solely upon the inputs of those delivering what is commonly viewed as health care services. If the co-production model has validity, you simply cannot get away from the reality that co-production partners who fail to have the requisite skills or desires to co-produce the desired outcomes will invariably lead to less favorable outcomes.

How do we get better outcomes? You have to first figure out what you are trying to produce and then figure out who are the key players in co-producing the desired outcomes. This is going to take some major culture change, in both patients and professionals with health care delivery.

Saturday, January 23, 2016

Assault on research transparency

We all suffer from various forms of isolation, some of it self imposed. I recently read the book, "The big sort" which identifies how Americans are increasingly self sorting in terms of where they live and with whom they associate. The authors come up with a compelling story about the results of that sort, which is we are increasingly unaware of opposing world views and opinions. The New England Journal recently published an editorial which I can only explain on the basis of scientific isolation. In this editorial, the Editor of the NEJM, Jeffery Drazen expresses reservations regarding data sharing and possible unintended consequences. (NEJM). I have to admit that he raises legitimate questions:
However, many of us who have actually conducted clinical research, managed clinical studies and data collection and analysis, and curated data sets have concerns about the details. The first concern is that someone not involved in the generation and collection of the data may not understand the choices made in defining the parameters. Special problems arise if data are to be combined from independent studies and considered comparable. How heterogeneous were the study populations? Were the eligibility criteria the same? Can it be assumed that the differences in study populations, data collection and analysis, and treatments, both protocol-specified and unspecified, can be ignored?

These are difficult to address issues which should be dealt with in the open! If these issues are part of the original data set upon which conclusions are drawn, all of the readers and consumers of the information should be aware of these potential limitations. Putting such data in the hands of an extended set of interested people should do nothing but add value to the original studies.

He then goes on to state:
A second concern held by some is that a new class of research person will emerge — people who had nothing to do with the design and execution of the study but use another group’s data for their own ends, possibly stealing from the research productivity planned by the data gatherers, or even use the data to try to disprove what the original investigators had posited. There is concern among some front-line researchers that the system will be taken over by what some researchers have characterized as “research parasites.”
What? Research work requires an investment of time and money, usually lots of each. The product of that investment may be data and from that are derived publications and hopefully some sort of impact on the world. If smart and motivated people can derive additional value from data derived from the original research teams, that is NOT parasitic. Depending upon who funded the research and who owns the data, the original parties may rightfully expect to derive some compensation and expect that they have a right to some portion of that additional value derived from the original data sets.

Obviously no one is going to make huge investments of time and effort to amass data sets only to have them coopted immediately. However, once one puts a publication in the public realm, the data upon which conclusions were drawn should be available to readers of that work.

The concern that the data could be reinterpreted with different conclusions seems frankly ridiculous. That this was published in one of the most prestigious medical journals in the world by the senior editor is outright embarrassing. Who did he have to critique this? He obviously has sorted himself away from necessary and critical peers who should have provided feedback to him and help him recognized the nonsense that this editorial is, before he published it.

Sunday, January 10, 2016

Resisting the Medical Machine - to what end?

There has been a gradual change in health  care delivery which has placed increasing financial pressures on all parties, patients, doctors and other billers for services, and payers. Where we find ourselves is a state where the health system is pressured to find more resources to pay parties more for the services they are delivering while simultaneously health care delivery is consuming a larger and larger proportion of economy.

The temptation is to look for scoundrels driving the cost side of the equation. There is no question that there are scoundrels but the truth is, all of the parties involved are to fault to some degree. We have a delivery system which has been blind to the cost side of the equation for much too long. Operating under the assumption that health care is different and that human lives are more important than money, we have been blind to the reality that there is a limit to this truth and it is a financial limit.

Health  care delivery is an expensive proposition. The more expensive it becomes, the greater the financial pressures created on the parties involved. The articles from the NYT and The Atlantic highlight the difficulties created in the production model of care, incentivizing physicians primarily via production targets.  (NYT)  (Atlantic)  As margins get squeezed for entities that are responsible for meeting payrolls and  paying the bills, they have few options; increase revenues or decrease costs. As much as we might not like this situation, it is an unavoidable truth.As Megan O'Rourke says in her article in the Atlantic:
The hospitalists assured the administration negotiators that their concern had nothing to do with money — that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue, according to several people in the room.
Until payment models are changed, physician payment will be linked to number of patients seen. However, in the absence of other measures than simply patient throughput and $'s generated, these will be the defaults. Whether quality measures can be developed which bear any real relationship to value added to patients and whether payments can be linked to actual value added (or be the driving force) is an unanswered question. The measures don't really exists for most encounters and the payments system still defaults to sheer numbers. I anticipate this will not change any time soon.

What it boils down to is the incentives are screwed up. This has implications not only for current physicians and patients but for future doctors and patients. Incentives now have impact on the decisions young people make about their careers in the future. It is no wonder that the most coveted fields in medicine are the ones that pay the highest now. For anyone who says it is not about the money, they might be right about selected people at selected points in time. However, incentives drive people and financial incentives, although they are not the only incentives,  they are still  the most powerful and ubiquitous incentives in place. Get them wrong and you create havoc.

How are the incentives wrong? It is hard to begin to catalog since  they are screwed up at so many levels. The use of third party payers has created an administrative system setting prices which works as  an accounting tool but loses all of the abilities of prices to coordinate economic activities.  Third party payment has also sufficiently insulated those receiving care from the cost to create all sorts of perverse incentives. Expensive interventions adding nominal to no value to patients become standard of care, a situation which would never happen if patients had real skin in the game. There are stories of financial impact on selected patients  but one thing our current system has done has been to insulate most patients sufficiently from the actual financial impact of how we operate to allow it to continue.

The production model of health care delivery is showing real strains as evidenced by the two articles I highlighted. As one of the comments from the NYT:

This is what happens when you apply a business model to healthcare. People aren't widgets. My great doctor, who spent time with patients and was a careful diagnostician, had her practice swallowed up by one of these hospitals. The last time I saw her, she apologized, but said she just couldn't making in private practice under the new business model for medicine. She was retiring early, she was broken hearted. You cannot put profits before people. 
However, you can put financial survival ahead of almost everything, which is exactly what is happening. Health care requires that a variety of people be incentivized to choose health care careers, get up to go to work, and decide to remain within the health care business. Get the incentives wrong and free people make rational decisions based upon the incentives in place. The doctor-patient relationship, however configured, has to make financial sense which means that physicians get paid from somewhere. I have few if any colleagues who have taken oaths of poverty. Ultimately the cost of physicians is borne by their patients, if not directly than indirectly. For a doctor who works 60 hours per week and makes $200K/year, assuming a 65% overhead, that means their patients need to pay them a minimum of $200/hour. That actually grossly under estimates the actual cost because much of the 60 hours per week devoted to patient care is billable time (time directly with the patient) under the current system. It is reasonable to assume that the cost is more like $400/hour.

However, patients are not aware that this is what the cost of their doctor is to them. They want their doctor and a relationship with their doctor, but I seriously doubt they can afford $400/hour or would be willing to pay this amount if they had to do so with their own money. So much for slow medicine. We also have to ask whether for most medical encounters it makes sense to pay this much for the value received.  When one is gravely ill this cost is likely money well spent. When one is dropping in for an annual social visit, perhaps there are better ways to invest this sum of money. The almost infinite variety of other doctor patient encounters yield a spectrum of value, ranging from great deals to lighting $100 on fire.

What we are left with are different parties all looking at the situation from vastly different perspectives. From the perspective of the doctors, they see environments pressing them to work faster and faster, putting patient's health at risk, and rewarding them for quantity but not quality. If they are to maintain their compensation levels, they are pushed to compromise. From the health care administrator's perspective, they are presented with competing priorities, diminishing revenues, and increasing demands from payers and patients. In order to deliver more with less, you need to get more from current investments, meaning more patients seen per doctor. From the patient's perspective, health care consumes more and more, both in terms of insurance premiums and payments for services, and the ambiance associated with the delivery systems seems more hurried and less caring.

The truth is we are all scoundrels and victims at the same time. We all bear some degree of culpability for the mess we are in and we all have  become victims of it dysfunction. For doctors, we long ignored the essential nature of being aware of how we brought value to our patients and measuring this objectively. We are playing catch up. We can't be the leaders of an industry now consuming what approaches to be 20% of GDP and not be at least nominally concerned about how to make this industry better AND more affordable. We self righteously claim that what we do is more important than profits but will accommodate to the production model  of "fast" medicine to maintain our compensation. For administrators, they are now trying to claim the moral high ground pushing initiatives such as patient access and becoming patient centric. However, they fail to fully comprehend what access means. Access to what? Who are our patients? What are their needs? Are there elements of care delivery that are more important than payer mix? And then there are the patients. They are the reason that the entire enterprise exist. However, patients now enter into the health care delivery morass not understanding that there are always trade offs and that resources that are spent to further some health care goal for them are resources that won't be allocated somewhere else. Truly valuing something means being willing to spend your own resources and the current system seems to more and more intent on defining what patients value with their own resources.

The health care enterprise does truly amazing things but sustaining and expanding its reach without bankrupting the country will require that fundamental changes in how we deliver care, how we pay for care, and how we think about the goals of the care system. The articles in the Atlantic and the NYT identify the symptoms but we simply cannot set the goal to slow the system down. How a meaningful transition to something different happens within such a regulated and risk averse industry is the trillion dollar question.

Sunday, January 3, 2016

Flawed testing

I saw a young patient in my practice this past week with a very difficult medical problem. She had a recurrent and painful condition which had defied characterization and treatment. I felt bad for her. Her life has been turned upside down.

My approach to such patients is marked by primarily by being persistent, mostly because effective treatment is often more about trying lots of things.  There is an awful lot of guesswork within present day medicine, whether we own up to it or not. My patient was not happy with my approach. I assured her that we could work through her problems and likely find a solution which resulted in clinically significant improvement of her state. It might take a while but I was optimistic. However, she thought I should do more tests. She simply could not believe that there was not some sort of off the shelf diagnostic tool which when applied would yield a quick fix to her problem.

In my opinion, there is a remarkable faith in the ability of diagnostic tests to sort through diagnostic conundrums. I think much of that faith is undeserved. The public's perception as to the power of "testing" is something those within the health care industry are more than willing to cultivate. The magical powers of examining a sample of tissue or blood and divine critical information which allows us to peer into the future or past gives power to those within the industry.

However, the real power and utility of those tests may not be anywhere close to what the perceptions may be. This is not unique to medical tests. A recent story in the Washington Post (Washington post story) underscores this. The FBI has now admitted that tools it has used to analyze hairs found at crimes scenes may not consistently yield useful information.
The admissions mark a watershed in one of the country’s largest forensic scandals, highlighting the failure of the nation’s courts for decades to keep bogus scientific information from juries, legal analysts said. The question now, they said, is how state authorities and the courts will respond to findings that confirm long-suspected problems with subjective, pattern-based forensic techniques — like hair and bite-mark comparisons — that have contributed to wrongful convictions in more than one-quarter of 329 DNA-exoneration cases since 1989. This included 32 death penalty cases.
Admission that the scientific underpinnings of our work has serious holes is a scary proposition. Information is power. The ability to predict and the ability to look back in the past and define truth is power. Power is money.

What is the best way to do good?

It is that time of year where we reflect to do better.  What is the best way(s) to do good? Do we improve the lot of humanity through intentional selfless action or indirectly, perhaps by generating sufficient wealth and then directing that wealth to selfless projects. In the former category one might see Mother Teresa, who attended to the sick and destitute. She dedicated her life to serving the poor, but it is not clear whether she raised anyone from poverty. Her apparent selflessness was only possible because she raised millions of dollars from those who had previously generated wealth.

In contrast, think of Bill Gates. Bill Gates did not start out as a philanthropist. He started out as an  entrepreneur. Only later in his life did he redirect his efforts, only after making billions developing and selling software. His positive impact on the world began well before he retired from Microsoft and began to dole on money via the Gates Foundation. There are many other examples of people who produced a legacy of positive impact on humanity, first by generated huge wealth by implementing a successful business that met human needs (Henry Ford, Andrew Carnegie, Robert Woodruff) followed by the creation of Foundations which keep on giving.

I think the best way to make an impact is to commit yourself to work hard in the service of others early in your life. Aspiring to leisure and self indulgence is no way to make the world a better place.
As David Landis wrote in his book "The Wealth and Poverty of Nations (pp 523-524)":
...What counts is work, thrift, honesty, patience, tenacity. To people haunted by misery and hunger, that may add up to selfish indifference. But at the bottom, no empowerment is so effective as self empowerment.
 Some of this may sound like a collection of clich√©s - sort of lesion one used to learn at home and in school when parents and teachers thought they had a mission to rear and elevate their children. Today, we condescend to such veracities, dismiss them as platitudes. But why should wisdom be obsolete? To be sure, we are living in a dessert age. We want things to be sweet; too many of us work to live and live to be happy. Nothing wrong with that; it just does not promote high productivity. You want high productivity? Then you should live to work and get happiness as a by-product.
Not easy. The people who live to work are a small and fortunate elite. But it is an elite open to newcomers, self selected, the kind of people  who accentuate the positive.
In addition, listen to what markets tell you and commit yourself to what the world values in a tangible way. Do first what others value in a tangible way. That way you can also generate wealth which serves multiple purposes. While few of us can ever expect to be as wealthy as Bill Gates, we can aspire to be sufficiently wealthy to where we can empower ourselves to be of value to others and create a sufficient buffer that we can take care of our real needs.

Money and wealth are not an end in themselves. However, they are essential to lift people out of poverty. We cannot rail against poverty and wealth simultaneously. Similarly, we should not get hung up on "things" but we also need to be mindful that humans are physical beings with physical needs and in the absence of "things", life can be brutish and short.

Think about your resolutions for the New Year. Which ones are targeted toward self improvement, leaving only you better off or feeling better about yourself and which ones will benefit others.