Tuesday, May 23, 2017

@pgpfoundation #FiscalSummit on #healthcare reform; livestream today




First, I hope everyone concerned about the economics of healthcare reform can join this panel discussion hosted by the Peter G. Peterson Foundation.

On their Web site there are other resources worth checking out, primarily this page dedicated to finding solutions to healthcare:
Improving our healthcare system to deliver better quality care at lower cost is critically important to our nation’s long-term economic and fiscal well-being. The U.S. currently devotes 18 percent of our economy to healthcare. Without reform, healthcare spending will grow to one-fifth of our total economic output within 10 years, which will make it increasingly difficult to find the resources to invest in other sectors of our economy.

At the bottom of this page there are more links to other resources discussing a fiscal solution to healthcare.

Friday, May 19, 2017

Quick scan: An American Sickness

I found out today about this new book published this past April: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by a tweet linking to a Medium post by the author Elisabeth Rosenthal. I instantly recognized this as an important read (maybe I even pride myself on that skill).


Certainly books and commentary about the broken delivery in the US healthcare system are the rage now, and justifiably so, but I hope to find an author who can do a better treatment (pun!) of the topic than the sanctimonious rest.

I had to run out and buy the book, but had to give it a quick scan just to confirm my intuition.

Rosenthal starts the book by exploring the American system and its ills (the hot mess that it is), by using the traditional way a new patient is interview by the clinician: History & Physical, which includes the chief complaint, history of present illness, the review of systems, of course the physical exam and any labs or imaging results that may be available. The a diagnosis is offered, actually a series of diagnoses based on probability called the differential diagnosis, if one diagnosis is not immediately apparent. Treatment option could then be explained.

This might seem like a cute trick if you've been to medical school, but I think it is important for everyone to be familiar with this procedure. People should understand and let's hope practice being a good historian when it comes to their medical histories.

Now the carnage begins on Medicine USofA, a kind of vivisection of the beast but in a thoughtful, analytical way that only someone with clinical experience could do a good job of.

I skipped to chapter 12 "The High Price of Patient Complacency." It rightly suggests the need for everyone to learn the knowledge and skills necessary to be an assertive patient. Unfortunately entering the medical system these days requires a battle mindset, anticipating the various traps and deceptions all meant to increase profits of the providers. This sounds very cynical, but hospitals and clinics have in mind to keep their practices should be moving from a cost to a profit center.

During this past election cycle, I felt that the American public would benefit from a full week of reports about how to become an engaged patient in a failing healthcare system, but we got something else.

I hope social can embrace later chapters of this book, and realize they is more hope than being stuck with a victim mentality, being a passive aggressive participant in a pursuit towards health both physical and financial.


@DoSpace: Adaptive Technology for the Visually Impaired

I just finished a fascinating conversation with Doug, the lead technical trainer for Outlook Nebraska, Inc. at DoSpace, Omaha. I asked his permission to blog about his story and his use of technology as someone who has been blind for 22 years, and has had a kidney and pancreas transplant, all as a result of diabetes type I.

His keyboard sits atop a closed laptop, and he has an earbud to hear the spoken version of the text he's accessing. He wears a continuous glucose monitor which is sync'ed with his iPhone so he has a real time readout.

For email, he says Microsoft Outlook is the best for accessibility, but notes Gmail is good but is not quite complete because it doesn't label images or buttons simply labeled as a "button." He uses the KNFB Reader for optical character recognition on his iPhone, whose final cost is over $100. He's very pleased with how it performs, except with round medication bottles. Doug mentioned that he has an advantage in the dimly-lit restaurants when reading the menu.

Outlook Nebraska employs 80 visually-impaired people, which is remarkable since 70% of the visually-impaired are unemployed. As it happens, accessibility devices for the blind are expensive, in addition to needed medication, so having an income is important. But Doug has developed a successful career following his passion for technology, and is looking to expand the market for the products Outlook Nebraska produces.




Patient engagement: news & trends

A very important topic for which I've been seeing some good resources:

High drug prices: Don’t let industry excuses go unchecked–or patient voices go unheard

Few Doctors Discuss Cancer Costs With Patients, Study Finds
The results of this study was released in anticipation of the annual ASCO (American Society of Clinical Oncology) meeting next month.

An American Sickness: How Healthcare Became Big Business and How You Can Take it Back
It's always interesting to note how I come upon an important resource. In this case, it was from a tweet linking to Medium post (above) from the book's author Elisabeth Rosenthal. I will be picking up the book today.

(more to follow...)

Friday, April 28, 2017

Can Patients Be Smart Healthcare Shoppers?

I'm finally getting around to reading this special section of the Wall Street Journal on healthcare from April 12.

First, I think you would to have some sort of diagnosis first because you went shopping for healthcare, unless you're acting in a proxy role such as a friend/relative or as the emerging trend of being a healthcare navigator.

It starts by citing a Kaiser Family Foundation survey that mentions the explosion in the growth rate of health insurance deductibles:


The Kaiser Family Foundation, a health-care research nonprofit, found deductibles for individual workers have soared in the past five years, rising 67% since 2010 without adjusting for inflation. That’s roughly seven times earnings growth over the same period.


Then they provide the Yes/No face off between Drs. Devon Herrick and Amanda Frost.

Devon's take is headlined: "There Are Simple Steps That Could Save a Lot of Money." He mentions the well-known trap of the free drug samples for new drugs that wind up with high prices for the refill.

Imaging studies, e.g. CT scans, can be less expensive at a diagnostic service rather that at the hospital, and you can save money further by offering to pay for cash, although this might not be applied to your deductible.

Because of the Internet, patients are becoming more healthcare literate, either by a trusted Web site or patient forum to understand and evaluate all the options for a particular diagnosis. But here's the problem: the diagnosis might not be certain or compete with a number of other potential diagnoses. This is known as the differential diagnosis. Unfortunately common illnesses tend to present differently for each individual, with a paucity of "classic" presentations. It takes a sharp clinician to discern troublesome cases, or the patient has to see a specialist, or even a series of specialists to find the right diagnosis. This is the case where the consumer approach becomes more difficult.

Amanda's retort is: "The System Is Too Complex for People to Make Useful Choices."

She says "Advocates for price transparency would have use believe that we, as "consumers," should consider our health care a product to be shopped for, like a pair of shoes."

However, It is naive to think that merely presenting the options with the possible consequences to the patient works all the time. The physician has to be empathic to the patient's financial state, and how it might affect compliance. I remember being on the surgical service where a patient's hearth valve replacement had dehisced (broken open) because she decided to stop taking the antibiotic for her systemic fungal infection, but instead using the money for other purposes.

Certainly healthcare is complex (even though we know the starting point of a treatment, we cannot be assured of the outcome for each patient), by some attempt has to be made by the patient with whatever help is available. And, again this present the need for a healthcare navigator who might be able to make is easier to explore options from a more practical standpoint, offering another view.

Another problem not mentioned is that patients for the most part don't have a grounding in basic medical science and might think that they may save money by not taking the complete prescription of an antibiotic, say, "saving" it for the future or even offering to friend for an undiagnosed condition.

There are caveats to the limits of healthcare shopping that patients need to know about, and it should never become about making judgments of what is bad or good care. Improved decision making requires that desire to look at information from different sources and take the time when it's possible to carefully choose a plan of action.

Monday, March 30, 2015

"There Will Never Be a Cure for Cancer" Until the DNA Puzzle is Solved

I was sitting in the med school auditorium for the special speaker of the day--Alfred George Knudson, Jr. M.D., Ph.D winner of the Albert Lasker Award for Clinical Medical Research (1998).

Through his statistical analysis of eye tumor (retinoblastoma) occurrence, he formulated a hypothesis that cancer occurred because of accumulated DNA mutations. (His 1971 paper was met with skepticism). This led to the discovery of cancer-related genes, when it became apparent that cancer is DNA disease.

For his introduction, one of our cancer researchers started with a description of his own institute ending with something like "And, hopefully someday we will finally find a cure for cancer." This type of platitude I'd expect from a politician, but I was glad it marked the end of his intro.

Up walked Dr. Knudson to the lectern and in a most wry manner said:


"There will never be a cure for cancer."

Certainly an excellent riposte to the introduction and it piqued the curiosity of the audience including me. He continued with: "Cancer is the result of cooking DNA in an aqueous solution at body temperature over a lifetime."

DNA is not the most stable molecule and there are "proofreading" enzymes that help correct mistakes as it's being replicated.



DNA was never considered the likely candidate responsible for heredity--such a simple molecule made of a variable arrangement of 4 base pairs. The thought was it had to be a protein of some sort, that would be complex enough to code for every molecule and process in a human from conception to senescence.

A renowned researcher Oswald Avery suffered outright attacks for his paper making this claim for DNA in 1944.

From The Great Influenza by John M. Barry:
Prior to Avery's discovery--and proof--that DNA carried the genetic code, he was being seriously considered for the Nobel Prize for his lifetime of contributions to knowledge of immunochemistry. But then came his revolutionary paper. Instead of guaranteeing him the prize, the Nobel Committee found it too revolutionary, too startling.
He never received the Nobel Prize.

The Nobel Prize Web site makes the following admission under the subtitle "Criticisms":
The failure to award a Nobel Prize to Oswald T. Avery for the discovery of DNA as the genetic material can be used as one example.
And now we're faced with conundrum of realizing that the human genome consists only of about 19,000 genes, fewer than some plants.

The more you understand it, the more incomprehensible it gets.

So DNA remains this simple molecule beyond comprehension, along with the cure for many cancers, until the puzzle is solved.



(NB: "Cure" for cancer is commonly expressed as 5-year survival rate. Re: Gene number, human genes can produce a number of products by the use of alternative splicing--another complex process.)