As I read your final blog and also read the posts that others wrote on your blogs, please take some time to reply to their comments and questions. It's not a grade, per se, but given all the work you put in to your blog and final blog, it is a good way to learn from what others posted and have a chance to respond.
So please, after you are done with the final, take a minute to read others' comments.
Thank you all for great work on your blogs, and for your comments.
The Obama administration and congressional Republicans and Democrats took added steps in 2015 that potentially could discourage overbilling and other fraudulent activities by changing the way doctors are reimbursed for their services. The Medicare Access and CHIP Reauthorization Act (MACRA) was designed to shift the medical system away from tradition “fee-for-service” and towards rewarding the quality of service in a bid to save hundreds of billions in the coming decades. But while the Obama administration took an important step last October by issuing the proposed new regulations to implement the law, they could be stopped in their tracks under the new Republican leadership at HHS.
Surprised? My guess is that an executive action cannot stop this, but who knows.
As of today, May 1, Northwest Healthcare is no longer in UnitedHealthcare's network - a contract termination that will affect thousands of Tucson area patients. As has been the case throughout the dispute, each side had its own version of what happened.
The end of the contract means patients covered by UnitedHealthcare will no longer be able to use Northwest Medical Center and Oro Valley Hospital, except for emergencies. They will also no longer be able to have visits to Northwest Allied Physicians and Northwest Healthcare urgent care centers, among others, covered by their insurance.
A contract termination affects UnitedHealthcare’s Medicaid, Medicare Advantage, individual and employer-sponsored plans (but not MediGap plans). UnitedHealth officials last week said they already had a transition-of-care plan in case the contract wasn't resolved.
Both sides of the dispute have written newspaper op-eds, as well as letters to patients (see below). Northwest Healthcare said it sent out more than 60,000 letters to UnitedHealthcare patients who had used a Northwest facility in the last year. It also set up a website called Stand Up to United Az.
Some Background
According to an opinion in the local paper, the CEO of Arizona Health Plans of United Healthcare, Dave Allazetta, claimed that
UnitedHealthcare wants nothing more than to continue our relationship with Northwest. In fact, we are offering to reward Northwest [Hospital] for the important services it provides to our members in Southern Arizona if the health-care system will commit to a value-based care model. Simply stated, value-based care means a portion of the health-care system’s payments from UnitedHealthcare would be based on how it performs against key quality measures and improved health outcomes for its patients.
It might be worth investigating what United Healthcare means by "a value-based care model." But obviously it seems much more complex than what is offered by United Healthcare. Given that Northwest Healthcare is owned by Tennessee-based Community Health Systems, it ultimately came down to them.
For those of you who will be here and are interested in the intersection of Cyber and medicine, the University of Arizona College of Medicine-Phoenix and the Atlantic Council are hosting the CyberMed Summit on Thursday, June 8 and Friday, June 9, 2017 at the University of Arizona in Phoenix. This first-of-its-kind simulated clinical cyber crisis exercise and discussion summit will feature notable voices in clinical medicine, security research, medical device manufacturing, and public policy. For more information see http://cybermedsummit.com and to RSVP, contact Anni Piiparinen of the Atlantic Council at apiiparinen@atlanticcouncil.org or 202-292-5164.
In addition to the readings on Doctor's Don't Listen, another reading from last Wednesday was on The Patient's Playbook. Here is a short (2 min) video from the CEO, Leslie Michelson.
Here is a quote from the article (linked):
Getting a scary diagnosis can be emotionally overwhelming. While it’s not always easy, the best approach is to summon the courage to ask tough questions, do more research on your condition, and get additional expert opinions. It’s essential to do this before before agreeing to powerful therapies or surgeries, as diagnostic error isn’t just inconvenient and frustrating: When you are misdiagnosed, you run the risk of receiving unnecessary and potentially harmful treatments.
Here are 8 essential questions to ask your doctor about a diagnosis. You should supplement them with questions that are relevant to your specific circumstances.
I understand that you believe I have this disease, but how confident are you in the diagnosis?
Is there anything else could this be?
Are there more tests that can be done to confirm this diagnosis?
Was the lab test sample good/the imaging clear? Would it make sense to get a second read?
Have you read all my medical records to get the full picture of my symptoms? Would it help if I went over them with you?
You say I have an abnormal blood test/a lab abnormality and that we can treat it with medication. But is it possible that this is indicative of a bigger problem? Are there other tests we should be doing to rule out serious diseases?
Before we move forward with treatment, are you confident we’ve explored all my options?
I appreciate what you’re saying, and it sounds very serious. I’d like to get copies of my lab reports/imaging/medical records in order to get a second opinion.
Here is a link to the book, Patient's Playbook. You can read more about this. After the 8 essential questions, I clicked on Toss Your Diet Books! Good Health Comes Down to 5 Simple Steps. There is a PBS video on "In Defense of Food" by investigative journalist Michael Pollan There's even a documentary about it (trailers shown below on this page - scroll down).
I saw this last year (Oct. 2016), and maybe you did, too. The language is explicit, and views of addicts and what they do to get their drugs. But it's relevant to our earlier conversation. He interjects his strange humor as he gets to the main points, which are important, especially Purdue's marketing of OxyContin.
Here is a series of articles related to our topic this week. Rather than add it to our readings, I thought we could comment here. Click on the author and Gazette-Mail link for access to the three articles. I'll post some thoughts below. But you can do the same.
Mr. Eyre (pronounced AIR), 51, won the award for a series of articles about the opioid abuse epidemic in West Virginia. Mr. Eyre, the paper’s statehouse reporter, began his multipart series with these words: “Follow the pills and you’ll find the overdose deaths.” It took Mr. Eyre years to acquire the documents most important to his reporting, and he did it “in the face of powerful opposition,” according to the Pulitzer citation. A lawyer defending a drug wholesale company said that it was vital to protect crucial court records “from the intrusive journalistic nose of the Gazette-Mail.”
From the first article, it's about collusion of the nation's largest drug wholesalers flooding notorious “pill mill” pharmacies in West Virginia's smallest towns and poorest counties with hundreds of thousands of painkillers, according to court records the companies had sought to keep secret for more than a year. Moreover,
West Virginia has the highest drug overdose death rate in the nation, and the deaths are climbing. Oxycodone and hydrocodone are the most widely abused prescription painkillers, and contribute to more overdose deaths in the state than any other drug. West Virginia spends more than $430 million a year on problems caused by prescription drug abuse, according to the state's lawsuit.
The series uncovered how small towns of 392 people were devastated from opioid overdoses. Look at the data, read the series, and comment.
It begins by noting that the 10,000 daily steps, incorporated as a goal into many activity monitors today, has not been scientifically validated as a way to lessen disease risk. So how much exercise might be needed in order to avoid heart disease has remained very much in question?
In a new study, which was published this month in The International Journal of Obesity, researchers at the University of Warwick in England and other institutions decided to examine postal workers in Glasgow, Scotland.
The Glaswegian mail carriers generally cover their routes on foot, not by driving, and spend many hours each day walking, the scientists knew. But the mail service’s office workers, like office workers almost everywhere, remain seated at their desks during the bulk of the workday. [So for the same group of employees, there are those who walk a lot and those who sit a lot. -sw] This sharp contrast between the extent to which the workers move or sit during the day could provide new insights into the links between activity and health, the scientists felt.
The researchers began by recruiting 111 of the postal-service workers, both men and women, and most between the ages of 40 and 60. None had a personal history of heart disease, although some had close relatives with the condition. They then measured volunteers’ body mass indexes, waist sizes, blood sugar levels and cholesterol profiles, each of which, if above normal, increases the chances of cardiac disease.
The variations turned out to be considerable. Some of the office workers sat for more than 15 hours each day between work and home, while most of the mail carriers barely sat at all during working hours. But the greatest benefits came from the most exaggerated amounts of activity. Those mail carriers who walked for more than three hours a day, covering at least 15,000 steps, which is about seven miles, generally had normal body mass indexes, waistlines and metabolic profiles. Together, these factors meant that they had, effectively, no heightened risk for cardiac disease.
The implications for what this means and how to get people to walk 4 miles an hour (and steps to achieve that) are discussed in the article.
How likely is it that people who think 10,000 steps are hard to do will increase it, when they learn it's not enough? More importantly, why did the industry think 10,000 steps was a good goal? Did one company start it and the rest followed?
In a couple of weeks, we will discuss alternative ways to treat patients. As I was following e-patient Dave's website, I found this graphic, called the Taxonomy of Burden (click on it to get a better view, and download it, share it. It's “Creative Commons Share-Alike with Attribution” – anyone is welcome to reuse it, as long as the credit is carried with it), Then I read further...
Dave learned about the graphic you see here, which was published last year as part of a paper in the journal BMC Medicine.
I love it. At the very center is one item: the word “burden.” Coming out from it are three dots:
Healthcare tasks: the things you’re told to do.
Consequences of healthcare tasks imposed on patients. (See above!)
Factors that worsen the burden of treatment: communication problems, getting to and from the doctor’s office, etc etc.
Then, extending from each, are additional realities: under Tasks are paperwork, understanding the illness, follow-up, rearranging life etc etc; under Consequences are impact on work, financial impact, etc etc; under Factors that worsen are the many many things that just plain get in the way of doing the right thing.
Why do I love this graphic? That whole thing could be printed out as an outline list, many pages long, but that has no “all at once” impact: you browse a list item by item, but this visualizes it all at once, making you realize: “Holy crap! Look at all this!”
I felt the same way. It's worth looking at it in some detail. It provides a sobering view of all the reasons why healthcare is so darn complex. But you knew that!
The diagram is from this article in BMC Medicine: bit.ly/TaxonomyOfBurden, by Viet-Thi Tran , Caroline Barnes, Victor Montori, Bruno Falissard and Philippe Ravaud.
Check out Dave's Resources link. The Communities link is especially interesting, but so is his blog. As you can see, I enjoyed reading it. Thought you might find it useful, too. 😊
Here is the info on the talk by Dr. Victoria Sweet, author of God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine. She is talking right after our class, and with a dessert reception. It's at the Marriott University Park at Main Gate, so it's pretty close by. (The link above is to her website).
I just found this brief article on Cigna's CEO changing approach to treatment of addiction. In 2014 alone, opioids killed 30,000 Americans becoming the number 1 cause of accidental death just surpassing car crashes. The importance of treating opioid misuse is identifying that behavioral health must be treated differently than physical health, and an alcoholic anonymous style treatment isn't the best solution. It goes back to what we learned about the importance of preventative health care, and avoiding opioid misuse in the first place. I recommend the reading! It's super quick but interesting.
Part 2: Here is a follow-up on this video after the new Healthcare bill (aka Trumpcare??) was proposed (again, language warning):
Part 1: Some of you may have seen this, but as only John Oliver can do, here is probably the best overview of what the Republicans are thinking about when they say "repeal and replace" Obamacare. (Warning: language, etc.)
I interrupt the healthcare debate with a brief discussion of blockchain, which in some convulated way is related to the debate, but also to discussion of data sharing. The article in Wired, starts by saying the new Secretary of Health and Human Services, Tom Price, came out against electronic health records, the digital histories patients make every time they see their doctor or go to the hospital. “We’ve turned physicians into data entry clerks,” he said, arguing that the burdensome recording systems need an overhaul.
As you should know by now, for decades (even before the ACA, but certainly after), many hospitals are still struggling with EHRs to address standardization and high quality health care. But while federal laws and incentive programs have made health care data more accessible, the vast majority of hospital systems still can’t easily (or safely) share their data. Enter blockchains. While blockchain is probably best known for powering bitcoin, it’s really a generic tool to keep secure data in a distributed, encrypted ledger—and control who has access to that ledger. This one shared ledger is spread across a network of synchronized, replicated databases visible to anyone with access. Which gives it unprecedented security benefits. Hacking one block in the chain is impossible without simultaneously hacking every other block in the chain’s chronology.
“Now is probably the right time in our history to take a fresh approach to data sharing in health care,” says John Halamka, chief information officer at Boston-based Beth Israel Deaconess Medical Center. “The EHRs may be very different and come from lots of different places,” Halamka says, “but the ledger itself is standardized.” Halamka gives a simple example: prescriptions. Say that one medical record shows a patient takes aspirin. In another it says they’re taking Tylenol. Maybe another says they’re on Motrin and Lipitor. The problem today is that each EHR is only a snapshot; it doesn’t necessarily tell the doctor what the patient is taking right now. But with blockchain, each prescription is like a deposit, and when doctor discontinues a medication, they take a withdrawal.
So, looking at a blockchain, a doctor wouldn’t have to comb through all the deposits and withdrawals—they would just see the balance. The software timestamps each validated block and adds it to a chain of older blocks, in chronological order. The sequence shows every transaction made in the history of that ledger (a chain of blocks - blockchain). And crucially for patient privacy and security, hospitals and pharmacies don’t have to send data back and forth to see it. They just all have to point to the same common ledger.
Feel free to add what you know about blockchains in other industries or businesses, or other details.
I posted quite a few articles on D2L related to possible changed to the Affordable Care Act. There are more after President Trump's State of the Union. I read a transcript with sidebars to offer a fact check and more detailed explanation.
I think the recent New Yorker article on Donald Trump learning that healthcare is "complicated" offers some very good links, include the Kaiser News Health Tracking Poll, which I also posted on D2L. The "complicated" article is telling. "I have to tell you, it’s an unbelievably complex subject,” President Donald Trump told a group of governors at the White House yesterday. “Nobody knew that health care could be so complicated."
Posted on 2/28, Ryan Lizza deciphers it for us:
“Nobody knew” is Trumpspeak for “I just found out.” Large-scale reform of the American health-care system is one of the most complicated policy issues the government faces, as all of Trump’s modern predecessors learned.
“The health care reform story illuminates almost every aspect of the presidency,” David Blumenthal and James Morone write in The Heart of Power: Health and Politics in the Oval Office, a 2009 examination of how eleven Presidents, from to Franklin Roosevelt to George W. Bush, grappled with the issue. “Because health reform is excruciatingly difficult to win, it tests presidents’ ideas, heart, luck, allies, and their skill at running the most complicated government machinery in the world.” (The book is on Amazon, and you can Read Inside.)
Lizza discussed the dived in the Republican party and ends noting that in their history of health-care reform, Blumenthal and Morone conclude with eight conditions necessary for passing major reform. The first, and perhaps most important, is “passion.”
“Major health care reform is virtually impossible, difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety,” they write. “The first key to success is a president who cares about it deeply.” Any President who is just learning the basic fact that health care is “complicated” has failed the passion test. And without that, little else matters.
The title of the post is based on another New Yorker article in the March 6 issue by Atul Gwande on TrumpCare vs. ObamaCare. In his commentary, Gwande points out that Republicans in Congress are facing the wrath of constituents who don’t want to lose those gains they now have with Obamacare. But even if there is a stalemate in Congress, insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system and American lives are at stake.
Why should a health plan be tied to where you work or live? The answer, of course, is "it's complicated." As Republicans debate ideas for repealing and replacing the Affordable Care Act, portability might play a central role in their plan. So how would that work?
The problem is that portability Is hard to define. The notion of "portability" means that consumers can stick with the same insurer, the same benefits and the same coverage limits, even if they move or change jobs. In the current policy discussion, though, portability is more likely to be viewed as a means for consumers to get access — possibly with the help of a tax credit — to a variety of health plans. But, the author (who is with KNN) says that "if keeping the same plan is the goal, that would be very tricky. The health care system is just not built that way." Read more to find out why.
I thought I would post this on the blog for you to comment, as well as add articles here for you to read. I did not pick these articles just to be critical of President Trump, but, as you know, when it comes to healthcare, it takes passion, careful consideration, and thoughtful policy discussions. Feel free to add your own thoughts, or your own readings.
I asked you to submit your proposal on D2L. In addition, you should update your personal blog (or shared blog), so we can all follow your work. Alternatively, you can post a comment here about what research questions you want to pursue as a way to focus the objective for your research, either as a group or individual. If you have ideas for data, let me know. I will also post data links on the blog. Comment here about specific data you would prefer, or like to have for your project.
We briefly discussed the nature vs nuture phenomenon with genes, and as I mentioned Siddartha Mukherjee, author ofThe Gene: An Intimate History, had a mother and aunt who were identical twins. The article points out that in the late 1970s a team of scientists in Minnesota set out to determine why identical twins are similar, i.e., how much these similarities arose from genes, rather than environments—from “nature,” rather than “nurture.” The question Mukherjee pursues is this:
Why are identical twins different? Because, you might answer, fate impinges differently on their bodies. One twin falls down the crumbling stairs of her Calcutta house and breaks her ankle; the other scalds her thigh on a tipped cup of coffee in a European station. Each acquires the wounds, calluses, and memories of chance and fate. But how are these changes recorded, so that they persist over the years? We know that the genome can manufacture identity; the trickier question is how it gives rise to difference.
The genome is not a passive blueprint. When one twin breaks an ankle and acquires a gash in the skin, wound-healing and bone-repairing genes are turned on, thereby recording a scar in one body but not the other. This article goes into some fascinating detail about how David Allis and many other scientists, figured out over decades that protein systems, overlaying information on the genome, generated the bewildering intricacy necessary for a cell to build a constellation of other cells out of the same genes, and for the cells to add “memories” to their genomes and transmit these memories to their progeny. “There’s an epigenetic code, just like there’s a genetic code,” Allis said. “There are codes to make parts of the genome more active, and codes to make them inactive.”
So, why are twins different? Well, because if you sequence the genomes of a pair of identical twins every decade for fifty years, you get the same sequence over and over. But if you sequence the epigenomes of a pair of twins you find substantial differences: the pattern of epigenetic marks on the genomes of their various cells, virtually identical at the start of the experiment, diverges over time.
I found the original video from George Church in 2007. His initial vision moved the dial on understanding and engineering years later. It is fascinating to look back on the beginnings. Take a look.
Also, here is the link to the video. The other two videos following this one (Webisode 2 & 3) tell the stories of two people who decided to share why they chose to post their personal genome with the public.
For a century, doctors have waged war against bacteria, using antibiotics as their weapons. But that relationship is changing as scientists become more familiar with the 100 trillion microbes that call us home — collectively known as the microbiome.
No one wants to abandon antibiotics outright. But by nurturing the invisible ecosystem in and on our bodies, doctors may be able to find other ways to fight infectious diseases, and with less harmful side effects. Tending the microbiome may also help in the treatment of disorders that may not seem to have anything to do with bacteria, including obesity and diabetes.
These links are worth investigating to learn more about the Human Microbiome Project (HMP). Judging
from a flood of recent findings about our inner ecosystem, that appears
to be happening. Last week, Dr. Segre and about 200 other scientists
published the most ambitious survey of the human microbiome yet. The Human Microbiome Project is based on examinations of 242 healthy people tracked over two years. The scientists sequenced the genetic material of bacteria recovered from 15 or more sites on their subjects’ bodies, recovering more than five million genes. This
project and other studies like it are revealing some of the ways in
which our invisible residents shape our lives, from birth to death. Here are some NIH demonstration projects at the HMP.
In this article, one interesting study (of many mentioned) is that a baby’s microbiome continues to grow during breast-feeding. In a study of 16 lactating women published last year,
Katherine M. Hunt of the University of Idaho and her colleagues
reported that the women’s milk had up to 600 species of bacteria, as
well as sugars called oligosaccharides that babies cannot digest. The
sugars serve to nourish certain beneficial gut bacteria
in the infants, the scientists said. The more the good bacteria thrive,
the harder it is for harmful species to gain a foothold.
As the child grows and the microbiome becomes more ecologically complex,
it also tutors the immune system, however ecological disruptions can halt this
education. Read more on how experiments on mice reveal how this happens.
Antibiotics
kill off harmful bacteria, but broad-spectrum forms [of antibiotics] can kill off many
desirable species, too. Antibiotics are likened to herbicides
sprayed on a garden. The herbicide kills the unwanted plants, but also
kills off the tomatoes and the roses. The gardener assumes that the
tomatoes and roses will grow back on their own. In fact, there’s no guarantee the microbial ecosystem will automatically return to normal.
Please read this articleand the links attached to the article (under Related Coverage). As you do so, let me know what you think.
So you not I'm not kidding about this. Hospital leaders in some cities in the UK, including London, said that patients with a body mass index (BMI) of 30 or above – as well as smokers – will be barred from most surgery for up to a year amid increasingly desperate measures to plug a funding black hole. The restrictions will apply to standard hip and knee operations.
A bit of background on this first. The National Health Service (NHS) was launched in 1948 as a combined payer and delivery system to replace a longstanding mix of private, municipal, and charity insurance. When introducing the bill which was written by the economist William Beveridge (hence the Beveridge Model in T.R. Reid' chapter), to the House of Commons in July 1948 - almost 60 years ago! - the newly appointed Secretary of State for Health, Aneurin "Nye" Bevan argued that the NHS would “divorce the ability to get the best health and treatment from the ability to pay.” Here is what T.R. Reid said about the NHS (pp. 104-105):
The NHS is dedicated to the proposition that nobody should ever have to pay a medical bill. In the NHS, there is no insurance premium to pay, no co-payment, no fee at all, whether you drop by the GP's office with a cold or receive a quadruple bypass from the nation's top cardiac surgeon. The doctor's bill is paid by the government, and the patient never thinks about it.
The Brits do pay for medical care, of course. They pay through a network of taxes that would make Americans cringe; the sales tax in the UK is 17.5% on anything you buy, while income and social security taxes are higher than America's in every income bracket. The Brits pay by foregoing treatments and medications that the NHS won't provide.
Now you might see where this is leading. The NHS controls its budget by controlling the range of medications, tests, and procedures it will pay for. Should a 49-year old patient get a hip replacement? Combining insurance and delivery of care in the NHS fostered a rational approach through the formal evaluation of therapeutic benefits against treatment costs. Yet because the NHS budget covers everybody, the money saved on one patient can be used to treat another.
Moreover, as the NHS secured annual increases averaging 6.3% during the 2000s, it grew to 20% of the government budget by 2009. As British government debt rose from below 40% of GDP in 2007 to 72% in 2010, worries emerged that above-inflation spending had saddled the country with unsustainable commitments.
Now when you read the The Telegraph's article, it should make more sense why there is rationing - and to expect more.
