Balance of Power

In researching a novel I am writing I have been reading about the history of the treatment of depression.  As often happens, I ran into an historical issue with echoes of the future.

Here’s an interesting paragraph from Howard Kushner’s book American Suicide.

“While asylum superintendents [in the 1840s] were as much captive of bourgeois ideology [the conviction that the insane could be reformed and that the suicidal could be cured] as were other social reformers, they were influenced on a daily basis by more parochial concerns.  Not least of all, these men sought stable employment in the medical profession at a time when, buffed by competing medical sects, medicine promised neither prestige nor a regular income.  A career as an asylum superintendent offered a solution to the contradictions between humanitarian desires to help others and a quest for economic security.  Like most professionals then and now, these asylum physicians saw no conflict between an increase in their professional power and the improvement of the condition of the patients they served.  Indeed, they viewed the former as essential for the latter.”  (Bold letters are my addition.)

Let’s look at that second-to-last sentence.  Professional physicians see no conflict between increases in power and the improvement of patient condition.  Conflict may not be quite the right word.  Maybe correlation is a better one.  Professional physicians see correlation between increases in power and improved patient condition.  Up to a point the statement is historically accurate.  There was no conflict in the eighteenth and early nineteenth centuries because as trained doctors from legitimate medical schools began to have more influence than the untrained barber-surgeons and apothecaries, patient health did get better.  Education and science eventually led to treatments that truly helped people.  This resulted in a medical profession which, unlike that of 1840, had great prestige and good income.

Since those early days of medical professionalization, however, power has shifted.  The turn away from paternalism toward autonomy has shifted the balance.  Regulation, legislation, and an omnipresent media have shifted it further.  Power, which used to be in the hands of doctors, for better or worse, is now in the hands of regulators, administrators, and the patients themselves.  The question is, does the decrease in physician power correlate with a change in the health of patients?

The answer, of course, depends on who you ask.

You could ask Timothy Quill and Howard Brody, who would tell you they doubt extremes of patient power increase the well-being of patients.  In 1996 they wrote the following in the Annals of Internal Medicine: (Ann Intern Med. 1996;125(9):763-769)

“At one extreme end of this [patient autonomy] spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician’s exercise of power and influence inevitably diminishes the patient’s ability to choose freely.”

You could ask the Physician Regulatory Issues Team at CMS, which claims that the power of regulation, in the form of government money, improves the condition of patients:

“Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients.” (http://www.cms.gov/Outreach-and-Education/Outreach/PRIT/index.html?redirect=/prit/)
You could ask Drs Bell, Wilkes, and Kravitz, who may say that the power of advertising is not improving anyone’s condition.  They found that “A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media.”  The Journal of Family Practice [1999, 48(6):446-452]
You could ask Louis Goodman and Tim Norbeck of Forbes, who would probably say that regulations are not increasing patient health.   “…Physicians are already spending 22 percent of their time interacting with insurers on formularies, claims, billing, credentialing, pre-authorizations, and quality measure data.  The workload can only increase with the new [ICD-10] codes.” http://www.forbes.com/sites/physiciansfoundation/2013/11/05/healthcare-is-turing-into-an-industry-focused-on-compliance-regulation-rather-than-patient-care/

You could ask the people of Florida, where doctors abuse their power of the prescription pad.  They would say that absolutely, regulation has improved the condition of patients.  An article in the New York Times reported that “New laws are also cutting off distribution [of prescription painkillers]. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” http://www.nytimes.com/2011/09/01/us/01drugs.html

Balance of power is important in health care, just as it is in government and marriages.  No one will argue that giving physicians full power to do anything they want is a great idea.  But we need to be careful about how much power we take away.

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NFL Players Host Concussion Summit Week Before Super Bowl, Despite Ongoing Litigation

Real innovation is often driven by those who think outside the box; those who take the obvious and make it an actionable reality. The week leading up to Super Bowl XLVIII, a group of entrepreneurs created a unique and transformative meeting of the minds. At the Coalition for Concussion Summit (#C4CT), Brewer Sports International and Amarantus BioScience Holdings, Inc. joined forces at the United Nations’ (UN) New York headquarters to bring scientists, biotech companies and professional athletes together, with the goal of building awareness and advancing scientific and medical opportunities for traumatic brain injury (TBI), chronic traumatic encephalopathy (CTE) and concussions. Add in the weight of immediate policy implications of the National Football League facing litigation for not properly informing or protecting players and Northwestern University’s football team attempting to unionize in hopes of improving athlete’s rights, and a perfect storm is created to demand change. Collectively, the week of the Super Bowl developed into an ideal time, location and platform for changing standards of health care and promoting developments in mental medical care that are patient-centric.

NFL Litigation

In the months preceding the 2014 Super Bowl, the NFL and the NFL Players Association (NFLPA) found themselves in a heated battle over the allegations that the NFL withheld information from the players about the depth and breadth of research indicating that concussions, memory loss and memory deterioration are linked. The NFL has since agreed to a $765 million settlement, which was recently denied by Judge Anita Brody who claims that the in the suit, “not all retired NFL football players who ultimately receive a qualifying diagnosis, or their related claimants, will be paid.”

While that decision is pending, more lawsuits are beginning to surface from individual players. Last Tuesday, former Detroit Lions running back Jahvid Best sued the NFL and helmet maker Riddell, claiming that concussion problems contributed to ending his career early

However, according to Robert Griffith, a 13-year veteran of the league, it doesn’t take a career-ending hit to significantly impact long-term functioning. “Guys suffer the same symptoms even after a few years in the league, including, sleep deprivation, depression, mood swings, addictions and self worth problems.”

The same week of the Super Bowl, the Northwestern University football team also dropped a bomb on the sports world, despite efforts from the National Collegiate Athletic Association (NCAA) to curb player concussions. The team wants to change the way university’s view, treat and educate student athletes, claiming more players’ rights are needed. This comes in tandem with a more than two-year long effort by several college players to sue the NCAA for failing to protect student athletes from concussions. An irony, pointed out by Chris Nowinski, author and former professional wrestler with World Wrestling Entertainment (WWE), who noted that “We have pitch counts for shoulders, even in high school, but we don’t have hit counts.”

Health Policy at the Forefront

When the NFL, the United States’ most powerful sports league, is on the hot seat for neglecting players’ mental and physical health, it is only a matter of time before public outrage requires policy change. Not only does the NFL itself have the ability to change health policy for the better, but the trickle down impact could save many young athletes around the country the trauma that current and past players have suffered.

Ultimately, a new standard of care is possible in the near future. Because, as Jermichael Finley told me, “100% or 50%, it doesn’t matter how one steps on the field. It isn’t if you get hurt, it’s when you’ll get hurt.” Further, as one conference goer attested, “We are speaking on the floor of the United Nations about brain trauma. This has never before been possible.”

With that in mind, researchers and clinicians such as Andrew Maas, MD, PhD, Robert Stern, PhD, Kim Heidenreich, PhD and Jay Clugston, MD came together with patients and biotech companies to discuss the current state of trauma, neuroscience, degenerative diseases, sports medicine and public policy.

Meeting Of The Minds

Despite the exorbitant power of the NFL, surprisingly little has been done to advance the conversation between athletes and the scientists who work diligently to understand and protect our brains. Until now.

As the nation’s best football players ascended upon New York and New Jersey, Brewer Sports International and Amarantus BioScience Holdings, Inc. gathered a room full of athletes and scientists to educate one another and discuss the real world of traumatic brain injury, concussions and memory loss.

“As a former NFL player, I am passionate about making strides to improve the health and safety of my fellow professional athletes, both former and current,” said Jack Brewer, CEO of Brewer Sports International. “Instead of pointing fingers, we have put together a world class panel of researchers to discuss TBI-induced neurodegeneration and CTE with those directly affected by and equally passionate about the cause as we strive to enhance awareness and work to find viable treatments.”

Gerald Commissiong, President and CEO of Amarantus reinforced the originality of the idea saying that, “The true innovation in #C4CT lies in bringing all of the stakeholders on the concussion issue into one forum. Conferences that are medical in nature almost always overlook key groups such as patients, caregivers and advocates. By allowing patients to be part of the process, we are creating a paradigm shift that we hope will galvanise the broader community into action.”

Brain Function

Despite Super Bowl caliber athletes having athletic abilities that are superior to most, the brains and vulnerabilities of these athletes are comparable to all others. The impact of one hard hit or one concussion can disrupt brain function forever. A point that resonates with Mixed Martial Arts (MMA) fighters as well. Just yesterday, boxing rivals met on Capitol Hill with Senators to support efforts of the Cleveland Clinic in studying brain health. They were backed by more than 400 of their peers who wanted to maintain their profession, but ensure that the future is brighter for other athletes.

Even veteran players such as Clinton Portis assert that he does not have regrets about his career but that he, “will not let my sons play contact football until at least high school,” due to the limited research that exists on TBI and concussions.

Those downstream effects, many at the summit contend, are highly linked to neurodegeneration, memory loss and long-term functioning. However, this is exceptionally hard to prove given how hard apples-to-apples comparisons are of brain damage and functioning. This association is further limited by the ability to compare impact enumeration and force due to the small sample size that are athletes.

Events such as the Coalition for Concussions Summit are becoming imperative to change health policy. When organizations, individuals, researchers and policymakers cannot fight the battle alone, it takes a meeting of the minds to advance a message. Hopefully, assembling key stakeholders to address health care problems will become a norm to improve health and care in the US.

 

Health IT Thrives With New Startup Companies

As the health insurance exchanges opened for enrollment just days ago, the federal government, including the President and the Department of Health and Human Services (HHS), had to acknowledge that it was not technologically ready. The IT infrastructures by which individuals tried to sign up for health insurance crashed and were unavailable throughout the first day and the weeks after. Those same sights were supposed to track enrollment, but proved to not be as well tested and far more expensive than originally anticipated. However, despite the shortages and disappointments with government IT readiness for exchange websites, there was a surge in US-based startup companies that demonstrated just how innovative and forward thinking technology can be in the health care arena. Nine new companies, all curated through BluePrint Health were introduced at that same time three weeks ago on “Demo Day,” and were ready to show the new frontier of health care, and how to transform care delivery through technology.

Health IT Incubators Driving Innovation

Blueprint Health is an accelerator program geared towards health care companies that want an intensive three-month mentorship to help find customers and capital, and learn from leading industry experts. The companies that are selected for the program range from individuals with a clever value proposition to well-established organization leaders that have existing customers, investors and are generating significant revenue, but with new ideas. According to Doug Hayes, a Principal at BluePrint Health, “We are seeing an acute need for innovation at the seed stage of the health care ecosystem. With top-down changes in regulations and quickly shifting incentive structures, the most successful companies will be those who can nimbly adapt.”

He asserts that what makes BluePrint successful is that it is, “uniquely positioned to attract, identify, and support the entrepreneurs that fill the gaps of service left in the wake of massive industry changes.” The accelerator program promotes the mindset that new businesses should not have to focus exclusively on fundraising. Hayes says, “Building a company is extremely difficult, and a founders’ time is best spent on customer and product development, not fundraising.” With that mentality, BluePrint does not use many pre-established filters when evaluating the near 1,000 applications it receives each year, but instead concentrates on business models.

The nine particular startup companies that were cultivated during the summer of 2013 range from Healthify, which focuses on creating platforms that connect and standardize medical homes to treat social needs to Board Vitals, an organization that improves the testing system of our nation’s providers. Each of these new businesses gives hope to innovators and entrepreneurs.

The Companies

Artemis

Artemis is a health care analytics firm specializing in benefit claims. With employers spending billions of dollars on health care, benefits managers need more information than the historical, once a year paper reports of the past. With the Artemis platform, benefit managers have graphical, real-time updates for claims and assessments. The creators claim that that deploying its tactics not only saves money for organizations, but also heads off future costs through prevention and determination of key cost drivers.

Board Vitals

Board Vitals brings together publishers, universities, and top physicians into a single digital platform for medical specialty education, with pass rates that are 10% higher than the national average. According to co-founder, Dan Lambert, “Content is continually voted up and down, meaning that the very best material comes to the top and outdated or incorrect content is voted out.” His partner, Andrea Paul added that their aggressive, but attainable, goal is to have materials for 20 of the 35 specialties in 2014.

CredSimple

The founders of CredSimple created a system to make the mandatory credentialing of physicians cheaper and more efficient. According to co-founder Garry Choy, at present, credentialing takes two to three months per physician and hospitals spend millions a year on the routine, but inefficient process. CredSimple uses an impressive 214 data sources to verify credentials, saving all provider parties time and resources, with downstream positive implications for entire hospital systems.

Genterpret

Pharmaceutical companies strive to gain pricing power and market share using genetic information about how patients respond to drugs. Genterpret, started by two system biology PhDs, links genetics to drug responses in one-third of the time (six months) of previous genetic testers. The faster turn-around time and vast outreach program created by the founders suggests that the Genterpret technology can soon be applied to thousands of diseases, improving health outcomes and saving money.

Healthify

After years of working in Baltimore health clinics, the creators of Healthify joined forces to start a company that addresses social needs such as food insecurities to improve health in communities. Medicaid spending on medical homes averages about $15 billion, much of which is spent on social needs. The data collected by Healthify will become vital as medical homes and accountable care organizations begin to address social needs as integral to overall health and well being.

ReferBright

ReferBright helps health practitioners with digital marketing in a world full of medical advertisements. The goal, according to the founders, is to improve outreach and referral rates for various kinds of professionals. Additionally, the automated system makes updating personal information easy for practitioners and makes vetting of practitioners easy for hospitals, knowing the information on ReferBright has been inspected and verified.

SpotMe Fit

According to co-founder, Jarrod Wolf, SpotMe, “allows employers to reward their employees for attending any fitness facility, running in races, or for using fitness apps and devices. When the barrier to incentives are removed–like eliminating paperwork and providing immediate rewards–and employees are given the flexibility to choose how they engage in fitness, then program participation rates skyrocket.” This focus on wellness and fitness programs is to improve health outcomes and lower health costs through incentives, monetary and physical.

Staff Insight

The premise of Staff Insight is to increase workforce productivity, specifically through hospital leadership being able to understand and staff facilities to the optimal levels. The company aims to use real-time dashboard to identify staffing levels in units, test baseline productivity, set new benchmarks for productivity and ultimately save revenue for facilities by optimizing productivity. The founders claim that early adopters have already seen a two to four percent increase in productivity.

WellTrackOne

WellTrackOne conducts a Medicare-approved personal assessment that hospitals can use to track patient data and identify potential risk factors. To lessen the administrative burden and disruption to the workflow, WellTrackOne claims that it can integrate all electronic health records, from multiple systems to improve data and health outcomes.

The Future Of Health Technology

Despite the federal governments success in getting support from professional athletic organizations and celebrities like Jennifer Hudson, the technological infrastructure just wasn’t ready for consumer usage. In contrast, Doug Hayes says that a key reason BluePrint startups were ready on Demo Day is due to the mentor community and outreach.

He claims that a by-product of their focus on business models and portfolio is that it, “includes many enterprise solutions. The long sales cycle and disparate channels within health care makes enterprise sales an especially tough nut to crack. However, our experience within enterprise and our mentor community, 150 strong, makes us especially well positioned to help founders sell into large payers, provider networks, pharma, and other enterprise customers.

 

Oh, Now You’re Jack Kennedy?

For Obama-Biden supporters, last night’s debate was a breath of fresh air on the heels of the President’s less-than-stellar performance in the first presidential debate. The left is calling a clear victory for Joe Biden, the right happy to call it a draw. Personally, I was just relieved that Biden opened his mouth and refused to let Paul  Ryan get away with what the Vice-President labeled “loose talk,” “stuff,” and “malarkey.” It was refreshing to hear Biden mention specifics and do so passionately, and disconcerting to hear Ryan once again fail to give specifics just as passionately. After all, he’s the numbers guy, so why didn’t he provide any?

This moderator, ABC News’ Martha Raddatz, did a far and away better job than PBS’ Jim Lehrer. She jumped in, cut off both candidates, and ran a tight ship. I really hope that Candy Crowley can follow in her footsteps when we get to the town-hall format on Tuesday. I also hope that President Obama decides to show up this time, and that he forces Governor Romney to explain his positions, rather than making vague statements in a last-ditch effort to pander to the middle. After all, both candidates have actual positions. It’s just that disclosing those positions isn’t always the best way to convince a plurality of Americans to vote for you. Particularly when you’ve already written off 47% of them.

Will last night’s respective performances matter? I doubt it. In that respect, I do think that the GOP is correct to call this a tie. Had Biden been as sluggish as Obama, or as gaffe-prone as he often is, it might have been seen as strike two, and could have further slowed Obama’s momentum, while increasing Romney’s. That didn’t happen. Right now, the overall score in this 4-game series seems to be tied 1-1. That makes Tuesday important, in that it gives the winner a slight edge, and the potential to close things out 3-1. Even then, though, it is questionable how much of an impact the debates will have on this election, as most folks have already made up their minds, and many of the undecideds may not turn out at all.