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Thursday, August 29, 2013

"Medical High School"? What?

Not kidding. I'm relocating from Las Vegas to the Bay Area. My wife works in Walnut Creek. Been a hassle for the past 5 years, this now-concluding "Virgin America Marriage" (and back to a real one). We're selling our Las Vegas house. The truck will be here on Sept. 13th.

Found a great, spacious place to lease out in Antioch ("Good Antioch," as the locals say, the south side). I can even bring my digital baby grand! Only about 17 miles or so from Cheryl's office, no freeways to contend with.

Looks like a "Bubble-icious" area to me, in light of the surplus of relatively inexpensive rents out that way. I'm gonna pay half what I'd have paid in Walnut Creek proper. This had to be one of those locales that got quickly built up all shiny and new and was subsequently populated by a lot of incautious buyers who took out pricey ARM loans and bought high, only to crash unceremoniously and painfully back to earth when the economy tanked about 5 years ago (my fav acronym of the era is the "NINJA Loan" -- No Income, No Job, or Assets).

So, I'm surfing the ZIP 94531 area on Google Map last night, zooming in and out, scrolling up and down, panning left and right, when I run across this maybe a mile away from our new digs: "Dozier-Libbey Medical High School." What?

Indeed. Wow.

They call it a "pathway school." Below, sort of their Mission/Vision Statement.

What's not to love? Get to 'em early. I've reached out to this school to offer to be a volunteer in any appropriate manner they might see fit to use me. I bet the kids that go to this school are really bright, really teachable. I'll have the schedule flexibility.

We'll see. They're probably wondering "who the heck is this guy?"

How nice. This is an idea that should spread nationwide, in light of the severe and growing need for astute people in every aspect of health care.

apropos, my Rolling Stone email newsletter popped into my inbox a little bit ago, and had a link to this:
Jerry Brown's Tough-Love California Miracle
The 75-year-old governor rescued the Golden State from financial ruin - and is reshaping a national progressive agenda

...Just two years ago, the idea that California could be a global model for anything was laughable. When Brown took office, the state was staggered by double-digit unemployment, a $26 billion deficit and an accumulated "wall of debt" topping $35 billion. California was a punch line for Republican politicos – a cautionary tale, they said, of the fate that awaits the nation should it embrace Left Coast-style economic, social and environmental liberalism. On the campaign trail in 2012, Mitt Romney joked that "America is going to become like Greece, or like Spain, or Italy, or like . . . California."...

he California that Brown inherited on his return to office appeared to be an insolvent, ungovernable mess. California's finances have been out of wack since the late 1970s, when right-wing, anti-tax activists passed Prop 13, a constitutional cap on property taxes that also requires a two-thirds supermajority vote to raise any tax through the state legislature. Moreover, it was a Republican, Arnold Schwarzenegger, who hastened the recent fiscal calamity by slashing California's vehicle license fee. Promising to cut the "car tax" keyed Schwarzenegger's victory over the hapless Democrat Gray Davis in the recall election of 2003. But it also blew a $4 billion annual hole in the budget that Schwarzenegger simply papered over with bond debt.

When the Great Recession struck and the state's credit rating collapsed, California was in a bind: Its budget shortfall was too massive to resolve with cuts alone. But the state's intransigent minority of Republican lawmakers refused to raise revenues. Making matters worse, in the same 2010 election that returned Brown to office, Californians tied his hands by approving another hard-line anti-tax proposition that reclassified many state fees as "taxes" and even made closing tax loopholes subject to supermajority rules...

Curbing climate pollution is just one way Brown is working to breathe new life into the ambitious agenda President Obama pursued in his first term. The nation's most populous state is also leading the country in the implementation of Obamacare – providing a critical test case that a model pioneered in Massachusetts can work, at scale, in a massively diverse state where nearly one in four residents lacks health coverage. "It's not too much to say that the success or failure of California will determine the fate of the legislation going forward," says Tanden, who helped craft Obamacare as a senior administration adviser. "I believe it will be a success – they're way ahead of everyone."

In June, Brown signed legislation adopting Obamacare's generously subsidized expansion of Medicaid to the working poor. Ever budget-conscious, Brown had been wary of the "big costs" and "big unknowns" of growing a program that already accounts for 20 percent of the state's general fund. But unlike GOP governors – such as Perry in Texas – who have rejected the program out of hand, Brown pragmatically embraced the challenge and the opportunity to cover 1.4 million state residents. "We're going to move with commitment," Brown said, "because I do believe people do need decent health care."

California also made headlines this spring when it unveiled sample rates for individuals in its new insurance exchange, which will serve up to another 5 million residents. Many had predicted sticker shock as premiums adjusted to cover Obamacare's expanded benefits. Instead, the increases were modest and plans affordable. Even before federal subsidies, 25-year-olds can get coverage for $141 a month; 40-year-olds for $219. The system is working, health advocates say, because California used its bargaining power to force insurers to offer uniform products and compete on price. "We held insurers' feet to the fire," bragged Peter Lee, the governor's executive director for California's insurance exchange...

Having waged and won his 2012 ballot initiative by focusing on education funding, Brown is now transforming how that money gets spent. The governor's new budget begins by restoring school districts to their pre-recession funding. But it targets additional spending for districts with high concentrations of at-risk learners. "A child in a family making $20,000 a year or speaking a language different from English requires more help," Brown said, pitching the plan to the legislature. "Equal treatment for children in unequal situations is not justice." Of the state's 6 million public schoolchildren, 3 million come from homes that don't speak English. Two million live in poverty. Under the new formula, per-pupil funding in Fresno – a city in the agricultural Central Valley, where 92 percent of students are disadvantaged – will nearly double by 2020 to more than $12,000.

U.S. Secretary of Education Arne Duncan and Brown have clashed on policy in the past, with Brown decrying federal testing regimes that force students to regurgitate "quiz bits of information." But in June, Duncan praised Brown's "real courage" for implementing a reform that may sound like "common sense" but – given how America's schools have historically been funded – "is actually revolutionary."...
I'm glad to be "coming home" to California after 45 years. I was born in NY, raised in NJ and first came to CA in 1966, and then lived in North Beach San Francisco in 1967-68. I have never felt so at home anywhere else (I'm gonna be a BART-ridin' fool; oh! the reading I'm gonna get done).

Yeah, the state has huge problems. So what? See "How Jerry Brown Scared California Straight" and "Jerry Brown's Political Reboot."

On the topic of medical education, the latest lament over at
The Trojan Horse called Integrative Medicine arrives at another medical school
Posted by Scott Gavura on August 29, 2013
Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.

That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered...
"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. We recognize that there are vastly different types of practitioners and proponents of the various forms of alternative medicine and conventional medicine, and that there are vast differences in the skills, capabilities, and beliefs of individuals within them and the nature of their actual practices. Moreover, the economic and political forces in these fields are large and increasingly complex and have the capability for being highly contentious. Nonetheless, as believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy." - Phil B. Fontanarosa & George D. Lundberd "Alternative Medicine Meets Science, JAMA
...In the science-based, reality-based world, there is no yang that needs to be fortified, just as there is no such thing as a yin deficiency. Yet your licensed TCM practitioner can sell you horny goat weed which is Health Canada approved to treat your forgetfulness and cold lower back. And if the University of Toronto is successful with its new Centre for Complementary and Integrative Medicine, this type of material may soon be “integrated” into its medical and pharmacy education. The entire concept is absurd...

Moves to embed CAM into academic settings start with the assumption that “integrative medicine” is a good thing, in the absence of any data to show that is the case. Based on the information that does exist, it’s reasonable to assume that increasing the levels of “integrative” medicine at the University of Toronto will reduce and compromise the quality of medical and pharmacy education, and ultimately, the quality of care offered to patients. It’s sadly ironic that the University of Toronto, with a medical school lauded by Abraham Flexner in 1910, is now turning its back on those qualities, 103 years later.
 At Dozier-Libbey Medical High School, an emphasis on "science" is touted.

Would controversies pertaining to "integrative medicine" be a topic for senior "Medical Ethics"?


Just in, from The NY Times:

Ugh. My grandson Keenan is now a sophomore at St. Olaf College. He plays football. Loves it. Loves to hit and be hit. We worry about brain damage.


A doctor takes up the Fred Trotter challenge. "Why re-invent the EMR wheel? ... Here’s my answer to that question"
What medical records offer: High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need: No focus on billing codes, instead a focus on workflow.
What medical records offer: Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.
What I need: Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer: Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need: Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer: Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
What I need: A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.
What medical records offer: Organization of information is not a high priority, as physicians are not reimbursed for organized records. The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.
What I need: Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial. The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.
What medical records offer: Top priority is paid to billing workflow, with second billing given to in-office patient management.  The least attention is given to clinical workflows for patients outside of the office.
What I need: My priorities are 180 degrees from this. My top priority is keeping people outside of the office healthy and happy. which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.
What medical records offer: Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”
What I need: Task management is near to the top. I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”
What medical records offer: Mobile communication is becoming more available, but it is very much system centric., meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.
What I need: My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.
What medical records offer: Payment for health services generally depends on two things: a problem being treated and a procedure code and are therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.
What I need: I believe we should focus far more on reducing risk factors than on treating “problems.” My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.
What medical records offer: Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business. It allows physicians to give good care despite the system that rewards them for bad care.
What I need: The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system. The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.
Dr. Rob is a good guy. I follow his blog posts routinely. He recently went "direct pay" -- cash subscribers. No 3rd party billing (the still-principal focus beef against mainstream EMRs, i.e. "ONC certified" EMRs).


Aug 29 (Reuters) - Aetna Inc has decided not to sell insurance on New York's individual health insurance exchange, which is being created under President Barack Obama's healthcare reform law, the fifth state where it has reversed course in recent weeks.

The third-largest U.S. health insurer has said it is seeking to limit its exposure to the risks of providing health plans to America's uninsured, but did not give details about its decision to pull out of specific markets.

"We believe it is critical that our plans not only be competitive, but also financially viable, in order to meet the long-term needs of the exchanges in which we choose to participate. On New York, as a result of our analysis, we reluctantly came to the conclusion to withdraw," Aetna spokeswoman Cynthia Michener said...
Wonder how this will affect NY's newly approved "Oscar" HIX (if at all)?


An interesting aspect of packing up to move after being in Vegas for 21 years is running into long-forgotten items, such as papers and reports written long ago. The snip below is from a series of reports I wrote 20 years ago during my first HealthInsight tenure (then called "Nevada Peer Review") based on analyses of what were then called "HCFA data" -- basically large file dumps of Medicare claims data that included HIC numbers, demographic info, facility IDs, Attending IDs, admit and discharge dates, discharge destinations, admitting dx, principal dx, secondary dx's, px/tx codes, DRGs, etc.

A hot topic in those days was the "30-day readmit," patients discharged and then re-admitted to an acute care facility within 30 days -- a possible marker for poor quality care.

(The data were crunched and graphics rendered in Stata.)

20 years later, a priority topic for HHS/CMS study and improvement action under the PPACA "pay-for-performance" initiatives (P4P)? The ever-so-persistent "30 Day Readmission."

Maybe this time, given the significantly increased availability of EHR-borne clinical data supplanting claims data, we'll finally make some headway.

PDF scan copy of these ancien reports here (~18 mb. I omitted the voluminous tables).


Bloomberg has an interesting interactive presentation up:
Bloomberg ranked countries based on the efficiency of their health-care systems.

Each country was ranked on three criteria: life expectancy (weighted 60%), relative per capita cost of health care (30%); and absolute per capita cost of health care (10%). Countries were scored on each criterion and the scores were weighted and summed to obtain their efficiency scores. Relative cost is health cost per capita as a percentage of GDP per capita. Absolute cost is total health expenditure, which covers preventive and curative health services, family planning, nutrition activities and emergency aid. Included were countries with populations of at least five million, GDP per capita of at least $5,000 and life expectancy of at least 70 years.
I snipped out the top and bottom 10.

Not sure yet how I feel about these summary proxies for "efficiency." Do what degree do they reflect "quality"? And, if we define "value" as "Quality/Cost," can we get there from these data?



I just downloaded this from O'Reilly (free with registration).

...[D]ata and predictive analytics have driven ever deeper in­ sight into user behavior such that companies like Google, Facebook, Twitter, and LinkedIn are fundamentally data companies. And data isn’t just transforming the consumer Internet. It is transforming fi­ nance, design, and manufacturing—and perhaps most importantly, health care. How is data science transforming health care? There are many ways in which health care is changing, and needs to change. We’re focusing on one particular issue: the problem Wanamaker de­ scribed when talking about his advertising. How do you make sure you’re spending money effectively? Is it possible to know what will work in advance?

Too often, when doctors order a treatment, whether it’s surgery or an over-the-counter medication, they are applying a “standard of care” treatment or some variation that is based on their own intuition, ef­fectively hoping for the best. The sad truth of medicine is that we don’t always understand the relationship between treatments and out­ comes. We have studies to show that various treatments will work more often than placebos; but, like Wanamaker, we know that much of our medicine doesn’t work for half of our patients, we just don’t know which half. At least, not in advance. One of data science’s many promises is that, if we can collect enough data about medical treat­ments and use that data effectively, we’ll be able to predict more ac­curately which treatments will be effective for which patient, and which treatments won’t.

A better understanding of the relationship between treatments, out­ comes, and patients will have a huge impact on the practice of medi­cine in the United States. Health care is expensive. The U.S. spends over $2.6 trillion on health care every year, an amount that consti­tutes a serious fiscal burden for government, businesses, and our so­ciety as a whole. These costs include over $600 billion of unex­plained variations in treatments: treatments that cause no differ­ences in outcomes, or even make the patient’s condition worse. We have reached a point at which our need to understand treatment ef­fectiveness has become vital—to the health care system and to the health and sustainability of the economy overall.

Why do we believe that data science has the potential to revolution­ize health care? After all, the medical industry has had data for gen­erations: clinical studies, insurance data, hospital records. But the health care industry is now awash in data in a way that it has never been before: from biological data such as gene expression, next-generation DNA sequence data, proteomics, and metabolomics, to clinical data and health outcomes data contained in ever more preva­lent electronic health records (EHRs) and longitudinal drug and med­ical claims. We have entered a new era in which we can work on massive datasets effectively, combining data from clinical trials and direct observation by practicing physicians (the records generated by our $2.6 trillion of medical expense). When we combine data with the resources needed to work on the data, we can start asking the impor­tant questions, the Wanamaker questions, about what treatments work and for whom.

The opportunities are huge: for entrepreneurs and data scientists looking to put their skills to work disrupting a large market, for re­ searchers trying to make sense out of the flood of data they are now generating, and for existing companies (including health insurance companies, biotech, pharmaceutical, and medical device companies, hospitals and other care providers) that are looking to remake their businesses for the coming world of outcome-based payment models...
Yeah, to be sure. But, still, I worry about naive and slovenly analytics of "Big Data."

More to come...

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