Minor Thoughts from me to you

I'm sure this is just fake news. There's no possible way that President Trump and Elon Musk could both be wrong about medicine. The VA is probably loaded with Deep Staters who will stop at nothing to bring Trump down. 🙄

A malaria drug widely touted by President Donald Trump for treating the new coronavirus showed no benefit in a large analysis of its use in U.S. veterans hospitals. There were more deaths among those given hydroxychloroquine versus standard care, researchers reported.

The nationwide study was not a rigorous experiment. But with 368 patients, it’s the largest look so far of hydroxychloroquine with or without the antibiotic azithromycin for COVID-19, which has killed more than 171,000 people as of Tuesday.

The study was posted on an online site for researchers and has been submitted to the New England Journal of Medicine, but has not been reviewed by other scientists. Grants from the National Institutes of Health and the University of Virginia paid for the work.

Researchers analyzed medical records of 368 male veterans hospitalized with confirmed coronavirus infection at Veterans Health Administration medical centers who died or were discharged by April 11.

About 28% who were given hydroxychloroquine plus usual care died, versus 11% of those getting routine care alone. About 22% of those getting the drug plus azithromycin died too, but the difference between that group and usual care was not considered large enough to rule out other factors that could have affected survival.

Hydroxychloroquine made no difference in the need for a breathing machine, either.

Researchers did not track side effects, but noted hints that hydroxychloroquine might have damaged other organs. The drug has long been known to have potentially serious side effects, including altering the heartbeat in a way that could lead to sudden death.

Earlier this month, scientists in Brazil stopped part of a hydroxychloroquine study after heart rhythm problems developed in one-quarter of people given the higher of two doses being tested.

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Disclaimer: I am a 15-year employee of Epic, love my job, and love that we have a CEO who cares deeply about patient privacy as well as patient care. I'm not writing as a company spokesperson, but as a private individual who's frustrated by fake news and misinformation.

Recently, many, many news organizations have written about Epic's opposition to a new regulation from the Department of Health and Human Services that would make it easier to share medical records data with patients and apps. These organizations are saying that Epic opposes the new regulation because Epic opposes data sharing and wants to keep patient information locked up, in the pursuit of outrageous profits. Nothing could be further from the truth.

Epic loves data sharing. Patients are healthier and safer when every doctor, nurse, medical assistant, lab tech, pharmacist, etc. can see their full medical records. We developed:

• Care Everywhere and Care Anywhere—data sharing between Epic organizations and standards-compliant data sharing between Epic and non-Epic organizations
• MyChart—allowing enable patients to access their own data
• Lucy—allowing patients to easily consolidate their charts from multiple healthcare systems
• Share Everywhere—allowing patients to directly share their records with anyone in the world, even clinicians who are still using paper charts

Our concern about the new rule comes down to one reason: worries about patient privacy. Many, many Android and iOS apps earn revenue by selling user data. The majority of the time users are unaware that their apps are tracking them, unaware of how much their apps are tracking them, and unaware of how many different companies their apps are selling their data to. There is a real risk that giving apps access to your healthcare information could mean that those apps are reselling your healthcare records to anyone and everyone, without your knowledge or consent.

We published an open letter stating these concerns.

• Family member data may inadvertently be shared. The data sent to the apps might include family member data, without the patient realizing it and without the family members’ knowledge or permission. Almost all medical records contain family history, which may be threaded throughout the record.

After surgery, Jim’s doctor wants to prescribe an opioid for Jim during his recovery. Jim prefers not to take an opioid because his brother Ken struggles with addiction. The doctor makes a note about that in Jim’s medical record. When Jim’s health data is sent to an app, and that data is used, shared, or sold, Ken’s addiction status may become public without Ken’s knowledge or permission.

Jim and Ken’s story is similar to what happened to Facebook friends who did not give their approval for their information to be harvested by Cambridge Analytica.

• Apps may take much more of the patient’s data than the patient intended. There are no transparency requirements to make it very clear to the patient what data the app is taking and what the app will do with that data.

A wellness app offers Liz a cholesterol study and asks her to approve sending the app her lab results. Liz does not realize that the app has gathered all of her lab results, including sensitive information such as her pregnancy status and STD testing results. She does not know that the app will sell that data. Once her health information is out, she cannot pull it back.

We have always, and will always, support patients’ right to use their data as they see fit. However, it is the role of government to ensure that patients have the information they need to make those decisions knowledgeably, like they have for nutrition and food or labels in the clothes they buy. Patients must be fully informed about how apps will use their data, and apps and other companies must be held accountable to honor the promises they made to patients.

For patients to benefit from the ONC rule without these serious risks to their privacy, we recommend that transparency requirements and privacy protections are established for apps gathering patient data before the ONC rule is finalized.

Epic does not typically comment publicly on national policy issues. However, our goal is to keep the patients at the heart of everything we do, and we must speak out to avoid a situation like Cambridge Analytica. The solution has a clear precedent in HIPAA protections, and creating similar protections that apply to apps would make a difference in the privacy and well-being of millions of patients and their families.

Please. Before you jump on the bandwagon of people attacking Epic, take a moment to think about the privacy implications of your health records being used as an income stream for app developers.

Interesting.

One of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age.

It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms: One in five cancers found with mammography and treated was not a threat to the woman’s health and did not need treatment such as chemotherapy, surgery or radiation.

… an editorial accompanying the new study said that earlier studies that found mammograms helped women were done before the routine use of drugs like tamoxifen that sharply reduced the breast cancer death rate. In addition, many studies did not use the gold-standard methods of the clinical trial, randomly assigning women to be screened or not, noted the editorial’s author, Dr. Mette Kalager, and other experts.

Dr. Kalager, an epidemiologist and screening researcher at the University of Oslo and the Harvard School of Public Health, said there was a reason the results were unlike those of earlier studies. With better treatments, like tamoxifen, it was less important to find cancers early. Also, she said, women in the Canadian study were aware of breast cancer and its dangers, unlike women in earlier studies who were more likely to ignore lumps.

“It might be possible that mammography screening would work if you don’t have any awareness of the disease,” she said.

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Do Americans really pay more for healthcare and get less for it than most other industrialized countries? Avid Roy does some myth busting.

If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer? In 2008, a group of investigators conducted a worldwide study of cancer survival rates, called CONCORD. They looked at 5-year survival rates for breast cancer, colon and rectal cancer, and prostate cancer. I compiled their data for the U.S., Canada, Australia, Japan, and western Europe. Guess who came out number one?

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Dr. Pauline Chen, writing at the New York Times.

The researchers then compared these outcomes to those of patients who were not covered by Medicare and therefore not restricted to having their operations done at centers of excellence. Even after adjusting for individual patient risk factors and the specific type of bariatric procedure performed, they found no differences in complication rates or outcomes between Medicare and non-Medicare patients. Moreover, they discovered that many of the improvements had been under way prior to 2006.

In other words, the much-heralded policy of funneling patients to centers of excellence has had little effect on how patients do.

Over the past several years, I've seen lots of people talking about how this or that government program fixed this or that problem in the United States. And, almost invariably, I'll see economists pointing out that the trend line was already declining before the government got involved and that the government's involvement did nothing to speed up the change.

Without this research, this Medicare policy would have received the same praise even though it, too, deserves none of the credit.

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From Dr. Elizabeth Dzeng, at The Health Care Blog:

The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare pays for inpatient rehabilitation, which he would be eligible for to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay costs taxpayers approximately $21,000. $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland that added an additional $9352 or so of unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.

This is the problem with third party payment. When someone else is paying for your medical care, you have to follow their rules. And their rules will often force you to make dumber decisions than you would make if you were spending your own money.

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Gautam Naik, writing for the Wall Street Journal:

Inside a warren of rooms buried in the basement of Gregorio Marañón hospital here, Dr. Aviles and his team are at the sharpest edge of the bioengineering revolution that has turned the science-fiction dream of building replacement parts for the human body into a reality.

Now, with the quest to build a heart, researchers are tackling the most complex organ yet. The payoff could be huge, both medically and financially, because so many people around the world are afflicted with heart disease. Researchers see a multi-billion-dollar market developing for heart parts that could repair diseased hearts and clogged arteries.

Lab grown replacement organs using adult stem cells. Awesome. I see no reason to back down from my prediction that my generation will have a substantially longer lifespan than my grandparents' generation.

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Here's something interesting from my files.

Medical personnel are fond of saying that you can't practice medicine like a business. They often believe that their work is unique and can't be easily optimized by industrial engineers. But there is some room for improvement. Take scheduling. What if you did today's work today? Worry about next week, next week. Don't try to schedule it today.

A few doctors have started applying that principle in their offices and have found that their patients spend less time in their waiting rooms and spend less time waiting for an available appointment. And the doctors spend less time being overbooked and overworked. The concept is called "open access scheduling" and allows doctors to leave most of their time unbooked.

[P]atients start calling at 9 a.m. and are assigned 15-minute time slots on a first-call, first-serve basis. Those who want a traditional scheduled appointment can try for the two to three hours a day he reserves for advanced bookings, usually for annual physicals or patients who need regular follow-ups. A few extra slots are left open for walk-ins or emergencies.

This is the type of innovation and experimentation that you'd see more of, if patients paid for their care directly, giving them the freedom to shop around and consult different doctors. That kind of open ended market would also give providers more freedom to experiment with how they practice healthcare, rather than being tied to the rules of large HMOs and large group practices.

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Americans in urban areas think of dental services as a kind of regular maintenance. It's little different than changing the oil in your car and occurs about as often. But that's not true for everyone.

According to the Pew Center on the States, more than 40 million Americans reside in areas with a shortage of dentists. And individuals without dental health access often end up in the emergency room, which is more expensive for everyone.

Advocacy groups and some state legislators think an alternative type of dental provider, often called a dental therapist, can fill the void. Dental therapists don’t receive as much training as a dentist. But they can perform some of the same basic services — such as pulling teeth and filling cavities — under the supervision of a dentist.

In Minnesota and Alaska, the two states that have practicing dental therapists so far, some of the therapists are able to take their work on the road, traveling to rural areas to treat those who have little or no access to dentists — or who have limited dental coverage. The dental therapists charge less than dentists and are able to take all types of insurance, including Medicaid and Medicare.

“The bottom line is that it will cost a state significantly less to hire dental therapists to provide basic restorative care to the underserved,” said Julie Stitzel, manager for the Pew Children’s Dental Campaign.

How are America's dentists responding to this? Not well.

“The No. 1 obstacle has been organized dentistry,” Pew’s Stitzel said.

“What we’re opposed to is the delegation of surgical procedures,” Faiella said. “Everyone deserves the treatment of a dentist and the care of a dentist.”

He says ADA is developing a range of programs to address the gap — pushing prevention measures such as fluoride and dental sealants, emergency room diversion programs in which dentists partner with community health clinics to ensure people needing dental care don’t end up in the emergency department — and an ad campaign to encourage parents to make sure their kids brush twice a day.

An ad campaign. That'll certainly take care of the dental problems of America's rural population. After all, they deserve a dentist not a less personage. And if they can't have a dentist? They're better off having nothing.

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John Cochrane recently wrote about healthcare reform. This is the direction we need to go in, not Obamacare.

First, he talked about the insurance side of health care.

To summarize briefly, health insurance should and can be individual, portable, life-long, guaranteed-renewable, transferrable, competitive, and lightly regulated, mostly to ensure that companies keep their contractual promises. “Guaranteed renewable” means that your premiums do not increase and you can’t be dropped if you get sick. “Transferable” gives you the right to change insurance companies, increasing competition.

Insurance should be insurance, not a payment plan for routine expenses. It should protect overall wealth from large shocks, leaving as many marginal decisions unaltered as possible.

Preexisting conditions, lack of insurance by the young and healthy, and spiraling insurance costs– the main problems motivating the ACA -- are neatly addressed by this alternative. Why do we not have a system? Because law and regulation prevent it from emerging. Before ACA, the elephant in the room was the tax deduction and regulatory pressure for employer-based group plans. This distortion killed the long-term individual market and thus directly caused the pre-existing conditions mess. Anyone who might get a job in the future will not buy long-term insurance. Mandated coverage, tax deductibility of regular expenses if cloaked as “insurance,” prohibition of full rating, barriers to insurance across state lines – why buy long term insurance if you might move? – and a string of other regulations did the rest. Now, the ACA is the whale in the room: The kind of private health insurance I described is simply and explicitly illegal.

He finished by writing about the supply of health care and why we have expensive, low quality options.

So, where are the Walmarts and Southwest Airlines of health care? They are missing, and for a rather obvious reason: regulation and legal impediments.

A small example: In Illinois as in 35 other states7, every new hospital, or even major purchase, requires a “certificate of need.” This certificate is issued by our “hospital equalization board,” appointed by the governor (insert joke here) and regularly in the newspapers for various scandals. The board has an explicit mandate to defend the profitability of existing hospitals. It holds hearings at which they can complain that a new entrant would hurt their bottom line.

Specialized practices that deliver single kinds of service or targeted groups of customers cheaply face additional hurdles, as they undermine the cross-subsidization provided by “full service” hospitals. For example, the Institute for Justice is bringing a major suit8 by a specialty colonoscopy practice in Virginia, which local “full service” hospitals managed to ban.

... The increasing spread of medical tourism to cash-only offshore hospitals is a revealing trend. Why does this have to occur offshore? What’s different about the hospital location? Answer: the regulatory regime.

So, what’s the biggest thing we could do to “bend the cost curve,” as well as finally tackle the ridiculous inefficiency and consequent low quality of health-care delivery? Look for every limit on supply of health care services, especially entry by new companies, and get rid of it.

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John Goodman talks about why Obamacare was flawed from the very beginning.

Do you remember the debates over the Affordable Care Act, aka ObamaCare? Now that repeal of the law has become a major campaign issue, it may be helpful to remember why Congress passed it in the first place.

Early in 2010, as the climactic votes neared, a parade of the legislation's defenders—from the House, Senate and Obama administration—appeared across the media. All had the same message: pre-existing conditions. They named the names of families "victimized" by companies that had refused to sell them insurance, had canceled their coverage or had refused to pay their medical bills.

The message surely resonated, but how many people have actually been affected since the law passed? The Affordable Care Act established a federally funded risk pool—the Pre-Existing Condition Insurance Plan—that allows individuals with such disqualifying conditions to buy a policy for the same premium a healthy person would pay. About 82,000 people have signed up as of July 31, according to the Kaiser Family Foundation's statehealthfacts.org.

That is not a misprint. Out of a population of more than 300 million, some 82,000 have the problem that was cited as the principal reason for spending $1.8 trillion over the next 10 years and in the process turning the entire health-care system upside down.

There is a much better way to ensure people with pre-existing conditions and you don't have to federalize health care in order to do it.

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Specialization in cancer care could lead to better outcomes at the same price. Instead of having every hospital perform every procedure, it might be better to have hospitals specialize in different procedures.

“If all patients needing surgery for colon cancer were referred to hospitals that have consistently achieved mortality rates in the bottom half of all hospitals performing this operation, then the average mortality rate could fall from a rate of 3.8 percent to 2.4 percent,” Ho said. “And if all patients who require surgical resection for pancreatic cancer were referred to hospitals performing 11 or more of these operations per year, mortality rates could fall by half, from a rate of 6 percent to 3 percent.”

“We were concerned that the centralization of cancer care that would result from referring patients to a smaller set of higher-volume hospitals could give these hospitals additional market power to raise prices,” Ho said. “We also wondered whether higher-volume hospitals might have a different cost structure that would raise or lower costs per patient. We found no statistical evidence that hospitals that performed more of these cancer operations were able to charge higher prices to patients for these services. We found that costs per patient were indeed higher for hospitals performing more pancreatic cancer surgery. However, these higher costs were not passed on to patients as higher prices for patient care.”

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More ways to communicate with patients that we used to think were brain dead.

Scientists have been able to reach into the mind of a brain-damaged man and communicate with his thoughts.

The research, carried out in the UK and Belgium, involved a new brain scanning method.

Awareness was detected in three other patients previously diagnosed as being in a vegetative state.

The study in the New England Journal of Medicine shows that scans can detect signs of awareness in patients thought to be closed off from the world.

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It may turn out that fewer patients are actually in a vegetative state than we think.

Researchers are currently testing the Halifax Consciousness Scanner, a device that uses words and tones to measure brain function in patients that have suffered severe trauma or stroke-induced brain injuries.

... In developing the scanner, doctors first measure brain-wave patterns to create a picture of a healthy individual’s brain, which is then compared to the picture that is produced by an impaired brain.

Doctors are then able to determine the extent of the injuries and a long-term outlook for a patient’s recovery.

The team behind the Halifax Consciousness Scanner is hoping to test the device on more brain trauma patients and eventually have units in ambulances and emergency rooms to gain accurate brain status readings of unconscious and semi-conscious patients.

Researchers are also teaming with engineers to develop a hand-held consciousness scanner and headset.

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Competition is coming to the healthcare system. It's coming very slowly, but it is coming.

In Priceless, I hazarded a guess that employers could cut the cost of hospital care in half by engaging in medical tourism. It’s a variation on what is sometimes called “value-based purchasing” or “reference pricing.” In its pure form, the employer picks a low-cost, high quality facility and covers all costs there. If the employee chooses another hospital, the employee must pay the full extra cost of the more expensive choice. In Priceless, I argued that to take full advantage of the opportunities available, the patients must be willing to travel.

Several large companies are already trying the idea out. As Jim Landers explains:

Wal-Mart Stores Inc., the nation’s largest employer, will jump into medical tourism next year by offering insured employees no-cost heart and spine surgeries at Scott & White Memorial [in Temple, Texas] and seven other hospitals across the country…By using a hospital in the new narrow network, patients could save as much as $5,000 or more…

The hospitals in Wal-Mart’s network — including the Cleveland Clinic and Geisinger Medical Center in Danville, Pa. — have gained national reputations for both quality and value. Physicians and surgeons work under financial incentives rewarding improved patient outcomes.

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Many politicians were motivated to push for Obamacare because of how much money we're spending on emergency room care, for patients who don't have insurance.

Health care delivered in the emergency room is often derided as expensive and inefficient, the source of our health spending woes. Physician Robert O’Connor has a different way to describe emergency medicine: An incredibly good deal.

O’Connor chairs the department of emergency medicine at the University of Virginia School of Medicine. As an emergency room doctor, he is not unbiased in defending the work he and his colleagues do. He’s also pretty tired of all the rhetoric about emergency rooms as the health spending culprit.

He says that ERs only account for 2 percent of all health care spending—and argues that patients actually get tons of bang for their buck.

... Another surprising data point: Emergency room spending is pretty uniform across different types of insurance coverage. That challenges some of the assumptions that the uninsured tend to visit the emergency room the most frequently. As it turns out, 89 percent of emergency room patients have some form of public or private insurance.

How much government regulation should we do, if we're concerned about 2-4% of overall healthcare spending?

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The Congressional Budget Office has estimated ObamaCare will "reduce the amount of labor used in the economy by roughly half a percent" — about 800,000 full-time jobs. It seems likely that four especially steep cliffs — including two where marginal tax rates can approach 100% or more — will factor into work and hiring decisions.

The 50th employee: For companies with 49 workers that do not offer its employees health coverage, the hiring of just one more worker would carry a penalty of $40,000.

The low-income cliff: At 200% of the poverty level is a dividing line. Deductibles for married couples on one side may be $300 vs. $3,500 on the other, according to one estimate provided to the Kaiser Family Foundation by Towers Watson.

The moderate-income cliff: The cliff is even steeper for families at 400% of poverty. Just past that point, families would lose eligibility for ObamaCare subsidies, which can get quite valuable for older workers.

Older workers' cliff: Lastly, consider a 62-year-old worker with $38,500 in income, $4,000 from investments. Such a worker could qualify for a $6,500 ObamaCare subsidy, paying $3,700 toward premiums with perhaps a $2,000 deductible.

But if she retires and claims Social Security, with roughly $14,000 a year in benefits, her ObamaCare premium subsidy would rise to $9,400 with almost no deductible.

Factoring in a state and federal tax bill of $6,500, that worker would have an after-tax, after health cost (premium and deductible) income of $26,000, vs. $17,100 in the old early-retirement scenario. In other words, the pre-tax gap between working and retiring early would shrink from $20,500 to just $8,900.

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The National Federation of Independent Business (NFIB) published a breakdown of the coming changes to healthcare, due to Obamacare.

Employees will pay a long list of new taxes, some of them hidden. ... Drug companies will pay a new tax on brand-name prescription drugs, but the tax will be passed along to you through higher premiums.

Medical device manufacturers will pay a new 2.3% tax on their products but will pass the tax on to you through higher premiums. One industry analysis suggests this may cause a loss of more than 43,000 jobs. Medical devices range from bedpans to MRI machines.

Employees will lose choices. If your income and family size qualify you for Medicaid, PPACA won’t allow you to stay on your employer’s plan. Example: A couple with 3 children and income of $41,000 can get private insurance through an employer. If the couple has a fourth child, however, PPACA will force them to leave the employer’s insurance and go on Medicaid because the federal poverty level (FPL), which determines who is and is not on Medicaid, increases with family size.

If your household income tends to fluctuate, you may have to move back and forth between a private insurance policy and Medicaid – possibly multiple times per year. Each time this happens, you may have to change doctors, hospital, etc.

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While urgent care centers typically offer hundreds of medical services, they do not perform surgery and are not equipped to deal with life-threatening emergencies. In most cases, a doctor is on site, although care may be provided by a nurse or physician assistant who is also on staff. Many centers are busiest in the evenings and on weekends, when most doctors' offices are closed.

In the past, at least some of the patients who now go to urgent care centers would have ended up in hospital emergency rooms. While the typical $100 visit to a center is comparable in price to a visit to a doctor's office, an emergency room visit can cost more than twice as much. A 2010 Rand Corp. study found that almost one in five visits to hospital emergency rooms could be treated at urgent care centers, potentially saving $4.4 billion annually in health-care costs.

Better customer service (because of late hours and quick appointments) and lower price. What's not to like? I think the increase in urgent care centers is a very good thing for American healthcare.

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