Sean Khozin, MD, MPH

Less is not always more, but it can be good enough. The New York Times published an article yesterday showing “two starkly different paths toward death in New York City’s hospitals, one for patients at elite private institutions, another for those at public hospitals, according to new data compiled as part of a consumer rating system.” The data showed that despite getting more expensive and intensive care, including more physician referrals, elderly patients in their last two years of life in private hospitals had similar outcomes as those in public hospitals.

Although the article arrogantly goes into bashing the financial incentives of doctors in private hospitals for ordering more tests and physician referrals, the bottom line is this: the super aggressive throw-everything-at-the-patient mentality doesn’t usually make much of a difference in prolonging life. The reason most doctors do it is the fear of litigation. This is the burden of practicing defensive medicine and public hospitals can get away with doing less because their patients tend to have lower expectations than their rich “upper class” counterparts.

Maybe we should do our best to take patient care out of the hands of big hospitals and into the more sensible hands of independent outpatient physicians and specialty centers (the ones big hospitals have been fighting so hard). And, please, let’s also not forget about some kind of tort reform.

Myca + JP + Me = Hello Health

Coming soon to NYC

Redundant, inefficient, and impractical are some of the words that come to my mind when I think about many of the new ventures and products that enter the healthcare market. That’s why when I first heard about ZocDoc I was lost for words. They challenged my knee-jerk reactions to their counterparts.

Launched in September 2007, ZocDoc is a smart and rapidly growing company that allows people to easily find a doctor or a dentist in their area and make an appointment with them online. Doctors can be searched by specialty, availability, health insurance plans, and location. You can even read user reviews and ratings of doctors and once you’re ready to make an appointment, you can do it right on ZocDoc’s website.

I recently sat down with the co-founder of the company Oliver Kharraz, MD and talked to him about his company. Oliver is an ICU physician by training and before starting ZocDoc he was a junior partner at McKinsey & Company where he focused on healthcare technology and Electronic Health Records. He started ZocDoc with a McKinsey colleague named Cyrus Massoumi in response to what he said was “an accident.” Last year Cyrus was on a flight to New York and, because he had a sinus infection at the time, ruptured his eardrum upon landing. Naturally, he was in a lot of pain but it took him a few days to find a specialist to treat him. He simply did not have the information he needed to find the first available ENT doctor in his neighborhood and his insurer’s website was clumsy and cluttered with useless information about their network of physicians, some of whom no longer practiced medicine. “This is how ZocDoc was born – a platform that allows patients to find and book doctors online, instantly” said Oliver as he sipped on his diet coke and I on a glass of Cabernet Sauvignon. “Patients enjoy the fact that they can book 24/7, filter by insurance and location, and get background information and reviews on our doctors.” Doctors on ZocDoc can get a lot of exposure, which is a great way to acquire new patients and fill last minute cancellations and openings and even save time for the front office staff.

ZocDoc is free for patients and primary care specialties (family medicine, internal medicine). Soon they’ll be adding a full range of other specialties to the list. TechCrunch selected ZocDoc as one of the “40 hottest startups globally” and CNET featured them as a Webware 100 finalist for their 2008 competition.

Finally comes a healthcare technology company that adds real value to the doctor-patient experience. Well done ZocDoc.

More info: TechCrunch, Webware 100

Matthias G. Muenzer, MD, a gynecologist in Boston, recently presented the following 3 items as a poll to a group of physicians on Sermo about what all physicians have in common, regardless of their political or personal views. Within a few days, 304 physicians responded, 95% of whom strongly agreed with his vivid assessment:

• We want to serve our patients, not insurance companies nor the government
• We want to practice medicine independently according to our knowledge and judgment, and not be told what to do by insurance companies nor by the government
• We want to make a living on our own, we do not want to be given what insurance companies and government deem “appropriate” for us

Greg Scandlen, is the President and CEO of Consumers for Health Care Choices (CHCC), “a not-for-profit grass roots organization that represents the views of the health care consumer to policy makers and industry leadership.” Below is an excerpt from a talk he gave back in 1999 at a meeting of the AMA House of Delegates in California where he presented highlights of his program for reforming the American healthcare system as then director of health policy at the Cato Institute. His insights are as timely and accurate now as they were when he delivered the talk almost a decade ago:

• Individual Choice and Ownership of Health Plan. Workers get to select their own plan and keep it with them as they change jobs. If they don’t like the plan they’re in, they can “vote with their feet” and leave it behind.

• Vouchers or Defined Contributions from the Government and Employers. Employers have a legitimate interest in helping their workforce obtain coverage. It keeps productivity up if workers can get treatment when they fall ill. So employers can continue to fund the plan, they just don’t have to choose or manage it.

• Tax Reform. The states and federal government currently spend $140 billion a year on subsidizing employer-sponsored health care, but it does so in a regressive way. It needs to be made at least neutral so that all Americans get the same subsidy.

• Expand Medical Savings Accounts. MSAs rationalize spending on routine services. They are the best tool currently available for affecting the demand side of the equation. They should be made available to everybody.

• Reform the Insurance Market. There are far too many nit-picky rules in the individual market, including mandated benefits and restrictions on non-employment groups. We need innovation and a period of creativity in this market.

• Transition Issues. Making the change to an individually-owned system will take a while and there are a number of safeguards that need to be built in. These include state high-risk pools, for instance, and continuation of Medicare for those already on the program.

Stressing the possible collapse of the healthcare system in response to unwise policy decisions, Mr. Scandlen pointed out the following facts:

• Employers have had it up to here with paying all this money and getting nothing but grief for it. They may spend $4,000 – $6,000 per worker on health coverage, and all they hear are complaints that Viagra isn’t covered.

• Employees are fed up with being forced into a plan the boss selected. For most workers, the employer is the last party they would turn to for help with medical issues. If their daughter has an abortion or if they want more benefits for mental health care, the boss is about the last person they would talk to.

• Physicians are sick of health plans second-guessing their medical judgment. The reality is that medicine is still as much art as science. Doctors have to take a lot of subtle factors into consideration, including the look of fear in the patient’s eyes or the love of a family member.

• Politicians are weary of the unending growth of the uninsured and the complaints they hear from all the other groups.They know that something must be done — but they have no idea what.

It’s now more important than ever to heed the enduring insights of Mr. Scandlen and other like-minded visionaries in order to rescue our healthcare system from its current dreadful trajectory.

More info: The Cato Institute

One of the essential needs of a consumer-directed healthcare system is transparency on behalf of providers, i.e. full disclosure of fees charged by doctors and hospitals for their services and appropriate quality measures associated with each transaction. Since 2006, the Bush Administration has publicly endorsed the idea of having more information available to consumers on the price and quality of healthcare services, hoping that increased transparency will promote free market principles and competition in the healthcare arena, leading to reductions in the cost of services.

In 2006, Aetna started to provide consumers with online access to the rates it negotiates with physicians in several U.S. cities in the name of transparency. Members in some areas can access price data for the top 30 physician services in addition to information about physician performance and quality. Aetna has also been pushing hard for a California state Senate bill, reportedly one vote short of approval, that would force hospitals and providers to release cost and poorly-defined quality information to health insurers.

What Aetna is doing is a sneaky way of turning the buzz around the value of increased transparency in healthcare to their own perverse advantage. As a colleague of mine put it, for Aetna ” ‘quality’ is defined as compliance with a third party payer cookbook and ‘cost’ is defined as how much money doctors save the insurance company.” This is fake transparency and by no means consistent with the cost-reducing benefits of a consumer-driven healthcare system, which should facilitate competition among providers to offer the best care possible at the lowest price without the imposed restrictions of third parties.

Beware of such distortions. The insurance industry is only concerned with one thing: increasing their profit margins.

Massachusetts is pushing aggressively towards universal health coverage for its residents. At a recent briefing sponsored by the Alliance for Health Reform and the Kaiser Family Foundation, the architects of the state’s health reform plan bragged about the number of newly insured residents. The counterargument to their lofty rhetoric came from Grace-Marie Turner, the founder and president of the Galen Institute, a well-known public policy research organization in Washington DC. Below are some of the important points she raised about the Massachusetts health reform initiative as stated in today’s Galen Institute Newsletter:

• It’s easy to get people to enroll in health insurance if you make it free or nearly so to them. The great majority of those newly covered by insurance are in plans completely or heavily subsidized by the taxpayer. Of the 330,000 newly enrolled in insurance, at least 232,000 are getting free or heavily subsidized coverage.

• The hard part is convincing people who don’t get subsidies — and who face growing penalties for not enrolling — to buy insurance. And the state has the audacity to tell residents what they can and cannot afford to pay. For example, if your family income is $70,001, the state says you can afford to spend $550 a month, or $6,600 a year, for health insurance. If you don’t buy it or get a waiver, you will be fined. The penalty now is as much as $1,824 for a couple and will go up again next year.

• The plan is starting to strain the state budget as well. Gov. Deval Patrick has asked for $869 million for fiscal 2009, but state authorities warn the cost will be closer to $1.1 billion — about as much as the state pays for its total public safety budget. The state also is concerned about another 30,000 – 40,000 people who have job-based coverage now but could be added to the subsidy rolls as well.

• Insurance costs continue to rise. The state has approved a 12% rate increase for health insurance for next year.

• Some safety net hospitals are threatening bankruptcy. They still are treating a large number of people without health insurance, but the payments they receive for uncompensated care have been cut as part of the health reform deal.

• The state is finding that Massachusetts’ goal of universal coverage is increasingly elusive. Several hundred thousand people are still without health insurance and will be hardest to enroll because the majority of them won’t qualify for subsidies. They face rising health insurance costs, growing fines, or a complex waiver process.

• The shortage of primary care doctors is making it difficult in some parts of the state for people who are newly insured to find a doctor who will take new patients. One person wrote us: “Before, I was uninsured and couldn’t see a doctor. Then I made the sacrifice to buy insurance, but I still can’t find a doctor who will see me. So now I still don’t get to see a doctor, but it’s just costing me more.”

On the Galen Institute website, the following comment is posted from a Massachusetts resident regarding the state’s health plan and Grace-Marie’s analysis at the briefing:

I want to Thank Ms.Turner for being the honest voice on this awful law called chapter58.The facts she stated are true.We do not have “affordable” insurance but we are forced to buy into insurance with high dedutables and we must fill out masshealth forms that sign our property over to the state.The fact is when they asked the question on health insurance it was worded “would you want everyone to have health insurance?” This is why so many answered yes.The media will not report on this because they recieve advertising dollars from insurance industry.The state legislator are bought by the insurance lobbyist.The federal government is bought by the insurance industry.We cannot fight their wealth.The Commonwealth Connector and Health care for all are bureaucracies that do not care if we get affordable insurance.Jon Kinsdale head of Commonwealth Connector worked for Tufts insurance for 20years.John McDonough head of Healthcare for all is going to work in Washington DC.This Massachusetts health care law is a sham most get free or next to free care and they want the rest of us to pay for it.Two years later,most of us cannot afford their insurance so they are being fined.The state of Massachusetts has made beibg uninsured a crime.Thank You so much again Ms.Turner we do not have enough people willing to speak out for what this law is really doing to the middle income residents.

More info: Galen Institute, C-SPAN coverage of the briefing

Google Health Beta was launched earlier today. This is a free service that provides an online space for patients to store their health information and share them with healthcare providers. Patients can either enter their information manually or have them imported automatically from a small list of providers such as the Beth Israel Deaconess Medical Center, Cleveland Clinic, and Walgreens Pharmacy. Google is also offering “personal health services” in partnership with various organizations and medical centers. There is a Heart Attach Risk Calculator from the American Heart Associated (AHA) that uses the patient’s health profile to estimate their 10-year risk of having a heart attack. There is also a convenient retail medical service from Cleveland Clinic where “top specialists provide medical second opinions and pre-adoption and nutrition consultations.” The convenience, however, comes with a high price tag: $565 for a remote consultation ($745 if a pathology review is needed).

Google Health signals an interesting trend where online connectivity can expand patients’ choices and support market-friendly retail healthcare solutions. However, Google is far from creating real value for patients since lack of price transparency and widespread competition among medical providers are still leaving consumers operating in the dark and are the driving force behind Cleveland Clinic’s ability to charge whatever their hearts desire.

More info: Google Health, Cleveland Clinic

State of the art medical care usually comes with a high price tag, a reality that is fully palpable in the U.S. and starting to manifest itself in other parts of the world. A recent McKinsey Quarterly report estimates that healthcare spending in Japan can double as a proportion of their GDP in the next 30 years, mainly due to advances in medical technologies and the increasing purchasing power of healthcare consumers. In his recent book Crisis of Abundance, economist Arnold Kling describes dependence on high tech medicine as “premium medicine,” which he accuses of utilizing too much physical capital (such as MRI machines) and human capital (such as specialists). He also believes that premium medicine has created a cultural phenomenon that expects a high level of effort to diagnose diseases. That’s probably part of the reason too many people with a headache in the ER get a CT scan (the rest is physicians’ fear of lawsuits promoting the practice of defensive medicine).

It is interesting to note that most recent technological advances in medicine have been for diagnostic or procedural applications and physicians have done a great job adopting them. When used appropriately, these tools can be of great value but when it comes to managing the most important health problems of modern societies, i.e. chronic diseases, innovative solutions are almost nonexistent. Patients lack smart tools to help them manage their chronic diseases. A bluetooth enabled glucometer that allows wireless transmission of blood glucose readings to a central web-based database via a cell phone is good start but it becomes useless if the physician has no way of integrating the data into their medical documentation platform (8.5×11 sheets of paper in most cases) without disrupting their workflow. So patients are likely to continue to give their physicians coffee-stained blood glucose diaries with missing dates and pages.

Perhaps our best efforts can encourage investments in technologies that empower patients to better manage their chronic diseases in partnership and close collaboration with their primary care physician, who should also be enabled with tools that seamlessly integrate data collected from patients into an intuitively-designed electronic platform where every piece of data is meaningful and in its appropriate context.

Premium dollars going into designing novel methods of delivering healthcare services for the management of chronic diseases can substantially reduce the much larger spending on “premium medicine,” which in many cases comes into play when barriers to delivering quality care leave a diabetic patient with early heart disease and a trail of expensive diagnostic, therapeutic, and pharmacologic expectations.

More info: Crisis of Abundance, McKinsey Quarterly Report
Artwork: Francesco Clemente