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Sorry for switching back and forth, but I’ve decided to go back to blogger. approach just a bit too limited for my tastes…please follow us back at our old url:

Making drug trials relevant to individual consumers– use real world data

The NYTimes has a really interesting article today on real world testing of drugs.  How are consumers to be informed today?  There are limited head to head trials, and almost all of the data comes from highly selected groups of individuals under conditions that are nearly impossible to replicate in the real world.  Ivory tower medicine indeed, giving us the best case scenarios only…but far from the outcome impact for all the spend and utilization occurring in very different ways out in the real world.

Although thousands of medical studies are completed every year, most have relatively limited goals. They often carefully select patients who have few medical problems other than the one under study, making it easier to get one clear result. They may not look at effects over the long term, assuming that if a treatment helps initially, patients will be better off.

But while such studies can help a drug acquire approval or answer a restricted research question, they can leave patients and doctors in a lurch because they may not tell how the new drug or treatment will work once it is tried in real patients with complex problems. Such limited studies, while they can have value, may no longer be enough, particularly when care has become so expensive and real evidence more crucial.

“They are at the heart of why we have trouble making decisions,” said Dr. Scott Ramsey, a professor of medicine at the University of Washington.

Its an interesting question as to which should be the better gold standard in addressing the patient before a physician: randomized clinical trials with non-matching study populations or outcome databases with real world utilization of patients matching her symptoms?

This used to be a hypothetical question and rationale for the quest for the holy EMR (the one to unite them all).  However, recent advances in social networking using pools of individual experiences in places like Patients Like Me and Sermo bring tantalizing “wisdom of the crowds” potential in evaluating the effectiveness of various treatments.

As medical tools increasingly help us to personalize and segment populations, it forces a pause in how the delivery of the appropriate data and heuristics will occur.  In a world where we ask individuals to make choices, is our ivory tower approach to group statistics relevant to individuals who want the best for them?

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X Prize for healthcare?

Peter Diamandis - X PRIZE foundation

Image by Sebastiaan ter Burg via Flickr

The X Prize Foundation, which has previously created contests around private manned spaceflight and sending a robot to the moon announced a prize for fixing healthcare today (via Jay Drayer).  From a moonshot perspective, this is likely to be the most difficult to date…even for them to create relevant metrics from which to judge the winner.

Contest details will be worked out by early next year. But essentially the competition will look for ways to “dramatically improve” cost and quality, said Brad Fluegel, a WellPoint executive vice president.

WellPoint and X Prize officials note that U.S. health care spending is projected to reach $4.2 trillion by 2016, or 20 percent of the country’s gross domestic product. Such spending in other developed countries makes up 11 percent of the GDP or less.

The contest organizers are thinking big picture. Fluegel said they will look for a system of solutions instead of one or two improvements.

Potential solutions might involve ways to streamline insurance reimbursement or the medical claims process that reduce administrative costs. They also might include solutions that help patients better manage chronic conditions like diabetes.

WellPoint will then test the finalist ideas in its state markets. A prize will be awarded only if the solutions prove effective.

Unlike contests in the engineering world, social systems like healthcare have rulesets and goals that are largely undecided and unmeasurable.  So where you can define clear targets to show progress for feats of physical engineering, as a nation we have not decided what our targets are for our social systems like healthcare (for instance, what’s the right balance between improving chronic care medication vs. finding new cures?)

I’ll be very interested to see if the contest organizers are able to put together a clear and end-goal with objective and relevant metrics within boundaries that aren’t self-serving for contest sponsor Wellpoint.

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Health Consumerism– Cost savings on hold until shopping made easy

For those of you who haven’t seen it, BusinessWeek just came out with a nice primer on Health Benefits as we go into both elections and the annual benefit selection process.

As we would expect, microbusiness is the leading edge of benefit shifts, as these owners of very small businesses bear both the full brunt of benefit costs and need to determine appropriate trade-offs relative to business survival.  The statistic that floored me was how quickly employee benefits were being jettisoned by microbusiness due to cost.

More respondents—67%—reported having health insurance for themselves, as compared with 54.9% in 2005. However, there was a shocking drop in the percentage that said they’re providing coverage for their full-time employees. In 2005, 46.2% said they were offering employee coverage; in 2008 the number went down to 18.6%. That’s one of the most massive drops we saw in terms of all the questions we asked across both surveys, and the sole reason is cost, which was cited by 65% as the top barrier to providing coverage.

So it seems the cost-saving impulse is a strong one going into this year, and I’d expect, given the recent economic conditions that it will become even stronger.  So how does this reflect on the cheaper, HSA option?  The results appear to be mixed, largely because in many cases the savings don’t go to the worker, while they bear the burden of additional administrative confusion.

Plenty of folks simply don’t want to be their own health-care manager. After all, there’s little of the positive reinforcement that you get (or used to get) from managing your retirement account and a lot more paperwork and negotiation involved.

As the owner of a small business, the HSA-CDHP combination makes my life simpler and cheaper, as I can use the HSA account to pay for dental and eye care while pocketing the cost savings.  As a relatively low-frequency user of the health complex, this tradeoff makes a lot of sense for me…I’d rather spend the extra “health” dollars on good food and healthy activities (like my in-office elliptical machine, massage therapy tune-ups, personal training).

Goel says his COBRA insurance, which would have extended coverage for 18 months after he left his job as a McKinsey consultant, cost $450 a month—and it covered only him, not his wife. Instead, he’s spending $200 per month for a plan with a $3,000 deductible that insures both of them. “We’ve gotten our premium way down, which allows us to be protected without wasting tons of money that would go straight to the insurance company,” he says. In addition, since HSA contributions can pay for dental and optometry services, the Goels have eliminated the need to pay for those two areas separately.

However, the lack of transparency around pricing becomes very apparent while trying to shop for care.  Prices can be negotiated down significantly with a cash payment, but the process is laborious and frustrating, as many physicians don’t know what they charge for any given service, and their business department submits codes that pay a contract value that’s not clear to anyone.

The coming economic climate should accentuate the cost savings potential of consumerism in health…unfortunately we do not have a health shopping experience that is acceptable for mainstream users.  At HealthShoppr, we’re building some of these initial retail shopping experiences for health services…let us know if you’d be interested in working with us to build a health system that consumers can actually understand and use.

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Open letter to Congress: Reject the bailout (off-topic but still market-driven)

In this time where we set the financial future of our country, I urge you to vote NO on the Bush proposal.

Using fear tactics, and Machiavellian influence techniques, the Bush government has proposed a completely insane framework (that gives the Treasury unprecedented power) to attempt to give “concessions” that make the plan merely mostly insane (mortgage our financial future on the mere word or the “experts” who have badly predicted current events and have already panicked into allocating the taxpayers money on AIG, Freddie, Fannie, Bear, etc).  Both Republicans and Democrats who believe in Constitutional checks and balances should be appalled at the naked grab for power by an imperial executive branch.  These are the times that try men’s souls…and the time that we need to make a stand to protect our nation’s soul as embodied in the Constitution.  This will hurt our pocketbooks in the short run, but to do otherwise will continue the abuses against transparency and open discourse that erode the democratic values of this country over the long term.

As a physician entrepreneur working to change the healthcare sector, I know the issues with credit on Main St…and I can tell you the existing players aren’t helping to support my enterprise either.  But inserting politics that favor big players over responsible small business would completely undermine the faith I have in being an entrepreneur in this country– that if I do a better job than the big guys, they will fall and I can change the world.

The key issue is that the troubled banks have no connection to local communities, lax due diligence and risk controls, and balance sheets that make external investors wary.

Let them die…and clear space for institutions that have been more responsible…and we’ll see capital flow to the growth stories that fill the vacuum.  If the goal is to create a bridge for credit to Main St, then use the SBA as a tool to promote liquidity in the small business marketplace.

The old infrastructure of cheap credit and quantitative gambling must die…we didn’t stop it at LTCM, but we must take a stand now, rather than feed the habit of the junkie who wants another shot…only through death of the existing entities does a better, more risk-conscious financial system take form.

Bailing out the existing players just gives them another opportunity to take boiler room, fee-based tactics to foist bad paper on another game of financial chicken/ musical chairs.

VOTE NO on the bailout!

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Health 2.0: Addressable market opportunities

Peer-to-Peer ...

Image via Wikipedia

Interesting week in health 2.0, that was notable for a disagreement on the direction of Health 2.0 that turned personal between Matthew Holt and Dmitriy Kruglyak.

Fard Johnmar sums up nicely the potential steps going forward where the empowering/ democratizing models of health 2.0 meet real profit-sustaining enterprise.

Medical Decisions: This includes decisions about what medications physicians should prescribe and how to manage end of life care cost effectively.

Information Sharing: Providing valuable health data and education to consumers, providers, payers and others.

Medical Technology: Tools that help prolong lives, reduce administrative costs and meet emerging health needs.

Funding: Ensuring scarce health resources are allocated effectively and finding ways to stop breaking the healthcare budget.

To be successful, Health 2.0 companies must find clear ways to demonstrate to established health industry players that they can make a real impact on the four major problems I outlined above.  In the long run impact, not advertising dollars will determine company survival.

Its a good first step to defining where we as a community see the opportunities that will generate new businesses in health 2.0 and beyond.  The nice thing about highlighting opportunities is that as long as the basic needs are not well met, we will continue to see innovation that creates value every time these elements are addressed.  I would classify the opportunities a little differently than Fard, as follows:

  • Consumer decisions: Layperson-level decision support and information/metrics that helps consumers make decisions around everyday health, who to see when they need professional help, and navigation of options where next steps are not straightforward (ie end of life, experimental treatment pathways)
  • Provider decisions: Both qualitative and quantitative decision support tools that help providers deploy optimal treatments for their patients.  This could include peer to peer support, statistics and outcome projections, treatment comparisons, etc.
  • Care coordination: Information flows, data presentation, statistics, and oversight to coordinate care and highlight personalized priorities/highest impact activities
  • Therapeutic advances: Technological advances that allow for better treatment of specific issues
  • Finance: Reducing transactional expenses in the system, including billing, coding, underwriting, collections, overhead, etc.  This may include re-alignment of incentives, change in stakeholder payment structures/roles, business models, etc.

Where I disagree with Fard is that Health 2.0 companies need to prove impact to existing health industry players.  Instead, companies need to be able to pair traction against one of these issues with a business model that someone is willing to pay for (including advertisers).  The value chains created in the transition between wholesale. top-down manufacturing approaches and bottom-up consumer driven retail platforms will likely be a work in progress…and health 2.0 platforms looking to maximize their impact will likely need to create a new health systems infrastrucure.

The value of centering the system around consumers, as 2.0 technology does, will be reflected in new metrics to measure progress, likely:

  • Cost-value trade-offs vs. approved/not approved
  • Forward-looking individualized projections vs. standardized clinical trial results
  • Chief Complaint addressed vs. Review of Systems billed
  • Relationship vs. Volume
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Caregivers seeking vacations: Summer camp and now Elder “Respite”

The NYtimes has a look into the lives of the caregivers— adult caretakers who aid family members…in many cases these are parents caring for kids, but increasingly we’ve seen adult kids taking care of elder parents, as illness and disability may take away a parent’s ability to live independently.

This is another example of medical conditions taking place in a social sphere, not the biochemical pathways many of our medical personnel are trained to deal with.  A good health system would look to caregiver support as one means of keeping people with families vs. getting dumped into institutions.

For many of these people, the guilt of dealing with a parent’s condition combined with the unrelenting needs of a sick adult wear them down over time, and reduce their ability to connect with family and friends. Knowing that there are options to get away for a little bit, something in between full time care and the nursing home, seems like an idea who’s time has come.

But as health professionals and the federal government have recognized the strain on these family members — including higher rates of depression, hypertension, diabetes, sleep disorder, heart disease and death — a growing number of facilities now offer short-term respite stays. In its simplest form, respite might be a home aide a few hours a week or use of an adult day care service. To caregivers at the end of their rope, real respite means a short time away — what for anyone else would be called a vacation.

Most caregivers do not take respite vacations because they see them as an admission of failure, or they worry that something will happen while they are away. A paradox of caring for an elderly relative is that the burden is so big, many feel they cannot share it.

So for all of you who are caregivers or interact with elderly patients and their caregivers, keep in mind that “respite” is an option that can refresh and restore those who are giving more than they have to their parents…and could use a few days to recharge.

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