Category: Uncategorized

The market for health system analysis – the most broken market of them all

You’d think I’d be accustomed by now to famous pundits selling their bad health systems analysis from their large soapboxes. The truth is, I still get annoyed. Atul Gawande’s 2009 New Yorker piece – “The Cost Conundrum” was a memorable instance. It was a beautifully written and highly influential piece of policy advocacy. I’m not exaggerating when I say “highly influential”; President Obama was clearly taken with Gawande’s findings (see this 2009 speech). And, now we know (from this StatNews piece) the genesis of Gawande’s recent selection by Amazon, Berkshire Hathaway and JPMorgan Chase to lead their new cost-cutting disruptive healthcare venture was the same 2009 article. Gawande revealed the backstory in an interview at the Aspen Ideas Festival. Evidently the article so impressed Charlie Munger, Warren Buffett’s right-hand man, that Munger sent an unsolicited check in the mail to support Gawande’s work. One thing led to another and Atul Gawande got the job. Thus, I feel it is not inappropriate to point out that Gawande’s piece was WRONG WRONG WRONG in its analytics, findings and recommendations. Atul Gawande is probably a great surgeon and he’s surely a brilliant writer. One thing he is not is a health system expert.

 

In the New Yorker piece Gawande laid out what was driving US health care cost growth, and what US policymakers should do to contain it. In the piece he compares how much it cost to treat Medicare patients across “local health systems”. By scrutinizing the practices of “low cost” versus “high-cost” providers, he determined that policymakers can reduce costs in the US healthcare system by spreading the practices of the “low-cost” group. Here’s the rub. Gawande was looking only at costs for Medicare patients; that is, he was looking only at the healthcare services market segment within which prices are regulated by Medicare. This leaves out what is going on with the (larger) private insurance market. There is no reason to think that insights from the Medicare segment would apply to the whole set of delivery activities at the provider or provider network level. And, in fact, once someone checked, it turned out that the Medicare patterns look very different from those of private insurance.

MedCare vs priv costs us health

If he submitted his piece in my (admittedly, not-yet-existent) course on comparative health systems, I’d make him review the readings on segmented healthcare delivery systems and do it over. Unfortunately, he submitted it to a New Yorker editor – and thousands upon thousands of smart people learned his erroneous insights. Including, evidently, the US president and Berkshire Hathaway’s Charlie Munger.

 

An excellent piece in the NYTimes in 2015 – “The Experts Were Wrong” [also the source of the map graphic] drew on the work of Zack Cooper and others and explained the error in Gawande’s logic. NB: The link to Cooper’s work on the NYTimes site does not work – here is a working link. The insights from this analysis suggest that, to constrain health care costs, the  US should strengthen anti-monopoly regulation and pursue (much) broader price regulation. This work merits the attention that Gawande’s piece does not.

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What will UK health officials do with all that excess demand?

Ever growing numbers of drug_shortageUK citizens are turning to private, self-paid, health care in the UK.

Mark Hellowell’s excellent piece “How the NHS will die” examines the forces at work, and ponders what actions may be taken to resolve this ‘excess demand’ problem. When the problem manifested in the late 1990s, UK officials ultimately resolved it with 10 years of public expenditure increases. Few predict public expenditure increases sufficient to resolve the problem will be forthcoming this time around.

Health officials invariably pursue efficiency gains to close such gaps. Efforts to do just that in outpatient drug spending, however, appear to be rebounding with a vengeance – to eat up ever larger chunks of the healthcare budget. For much of the past year, the Department of Health has been forced to resolve widespread drug shortages with month-to-month agreements to reimburse pharmacies at prices much higher than the official NHS tariffs. The Times put the extra costs for April – November 2017 at ₤200M. Ben Goldacre and co at Oxford give a tally through December of ₤285M. And, the unpredictable reimbursement of higher-than-official prices works more as a band-aid than a solution, since the shortages don’t appear to be diminishing.

Am I being too pessimistic? Are promising developments underway that I’m missing? Silver linings to accompany the gray cloud?

Updating practitioners as knowledge changes: the (discouraging) case of dietitians

I’ve become increasingly interested in the mechanisms through which health systems bring about practice changes among frontline providers. Pharmaceutical companies appear to do much of the work to reach and educate providers, if the practice change involves deploying a new pharmaceutical product. For the many other changes, I’ve yet to identify any approach which reliably and rapidly works across health systems. Health systems rely heavily on practitioner retirement and new entry – where the new entrants are educated on the new practice in their professional education. As the rate of medical knowledge accumulation accelerates, dissatisfaction with existing mechanisms is sure to grow.

 

Among medical knowledge domains, nutrition science has experienced relatively rapid change in the past 15 years. Naturally, this makes me curious about dietitians. How is the profession dealing with the changes? More to the point (for those of us interested in health systems): how well are different countries’ mechanisms for deploying practice change responding to this particular challenge?

 

A July 2017 paper by McArdle et al in the Journal of Human Nutrition and Dietetics presented some alarming answers to this question in the UK. McArdle and co-authors studied dietitians’ practice – focusing on what they advise diabetic patients with regard to carbohydrate consumption. NB: this is a domain where the appropriate advice has changed substantially in the past few years; in a nutshell, dietitians should be advising carbohydrate restriction.

 

The inestimable Zoe Harcombe synthesized the key findings thus:

This article shows that dietitians generally are confident in their advice – diabetes specialists especially so. Yet, fewer than one third (29.4%) of dietitians would recommend carbohydrate restriction even 50% of the time. More, (32.2%), would never, or hardly ever, recommend carb restriction. In the uncommon circumstances when carb restriction is supported, 92% of dietitians would advise type 2 diabetic patients to consume more than 30% of their total energy in the form of carbohydrate. Only 1 in 320 would advise the therapeutic level of carbohydrate for the treatment of type 2 diabetes.

dietitian old photo
Let me just check my class notes…..

Health services research regularly confirms how difficult it is to change the practice of doctors. Apparently this applies to dietitians as well. Given how many people are suffering with diabetes, I’d say we can’t afford to rely on the “wait for retirement” mechanism to work.

The library in your living room: free ebooks from your public library

Free books. What’s not to like about FREE books? Nothing. Which is why I’ve always loved my local public library. Our public libraries have even more to love now – and I want to spread the word.

Public libraries throughout the US now offer their members access to a gold mine of digital resources. I will talk about ebooks here, but keep in mind they offer digital access to all kinds of classes and magazines, periodicals, and journals, and music and films too.

Free e-books. The majority of public libraries in the US ‘rent’ a digital collection of their choosing from a company called Overdrive. The Washington DC Public Library’s Overdrive ebook collection this year is 26,101 books, for example. Your library membership permits you to access this collection, and check out e-books, which you can then read either on an e-reader or tablet or (even) your smartphone.

How to get your free ebooks. To get a book on your tablet you need to download Overdrive’s app – Libby to your device, and then enter your library membership credentials. tablet ereader booksOnce you do this, you can browse your library’s collection, and check out or place a hold on the book of your choice. If you have a Kindle e-reader, you need to link to your Amazon account and then checked-out books will show up in the same place as Amazon purchased books, including on your Kindle (instructions from Amazon). To get a book on most other e-readers, you access Overdrive on your pc, via your browser, and download the book file using Adobe Digital Editions [free software; you need to register for an Adobe ID to use the software in this way; instructions from Overdrive]. Then you connect your e-reader to your pc, and transfer the book (instructions from Overdrive). There are different ways to do this, depending on your e-reader model. You might be using Nook software from Barnes and Noble for example.reciprocity list libraries

But wait. There’s more -> R.E.C.I.P.R.O.C.I.T.Y.

Now that you check out books digitally – the hassle of getting books from, and back to, the library, is gone. Yes, that’s right. No more overdue books. Ever. The library is, for all intents and purposes, in your home, in your living room, you might say. Now, when I tell you that all the localities in the DC metro area (see list) have a reciprocity agreement – you will naturally be very excited. Anyone eligible to enroll in one library, can enroll in any and all libraries. This gives you access to well over a hundred thousand ebooks. For free. From your living room. Truly an embarrassment of riches.

Happy reading my friends.

Is religion a bad or good thing for society? An engaged discussion between Sam Harris & Jonathan Haidt

Is religion a bad thing overall for society? The new atheists certainly seem to have a case. I’ve seen, first hand, too much evidence for the benefits coming from religion-based groups to be satisfied with this simple conclusion. The topic is an important one, clearly. I’d like to sort out what I think. I just listened to a very meaty discussion on this topic between Sam Harris and Jonathan Haidt – and I’d like to share it with you. But first, a bit of background.

I have been an admirer of Sam Harris’ work since I read his 2004 book The End of Faith: Religion, Terror, and the Future of Reason. Over time, I grew to have reservations about some of the more strident anti-religious positions taken by Harris and other leading thinkers of the “new atheist” movement. Reading Harris’ recent work, I’ve discovered his thinking on the role of religion in society is more subtle that I thought. Yes, he argues faith (the belief in historical and metaphysical propositions without sufficient evidence) is problematic because it is inherently irrational and excludes any attempt to criticize it. However, Harris’ most strident criticism targets fundamentalist forms of religion; adherents of fundamentalist forms of religion uphold belief in strict, literal interpretation of scriptures and commitment to societal changes to manifest the ideals described in those scriptures. I find Harris’ criticisms on this score persuasive.

I am also a fan of social psychologist Jonathan Haidt‘s work. Haidt views religion as playing a relatively benign role in society. In The Righteous Mind: Why Good People are Divided by Politics and Religion, he looks at the achievements of communities through sustained collective actions and concludes that religion has contributed to making these collaborations possible.

When Harris and Haidt clashed publically on this topic starting in 2007 [NB: they present an overview of their exchanges starting at minute 30 in the interview to which I link below], I found it amusing, at first. Upon reflection, I was annoyed. These two influential scholars present themselves as open-minded; both take strongly positive positions on the critical value of discourse to scientific and social progress. Yet, on such an important topic, they resorted, in my mind, to clever sniping rather than real engagement in what was behind their different views.

Last week, as I made my way through earlier episodes of Sam Harris’ Waking Up podcast, I made a happy discovery. Harris had invited Haidt to engage in discussion on his podcast in March 2016. I commend it to your listening enjoyment, for the substance as well as for the pleasure of hearing discourse that is engaged rather than entrenched. By engaged, I mean that the discussion helped illuminate the substance and limits of their disagreements. Haidt, for example, makes clear that his position that religious bonds can help a society to sustain collaboration toward their betterment, does not conflict with Harris’ argument about the harms flowing from fundamentalist religion. All in all, it was a much more interesting exchange than that which occurred in their heated sniping over previous years.

Waking Up Podcast with Sam Harris Episode #31, March 9, 2016

Evolving Minds: A Conversation with Jonathan Haidt

You can stream or download the audio from the podcast website episode page here or stream it from youtube here. Note: the exchange between Harris and Haidt starts at 26 minutes in; they first discuss their clash and their views on religion. Then they turn to political correctness and free speech issues on campus.

 

Best purchase ever: my adjustable desk

I have been spending considerable time every day interacting with a computer since at least 1987. I barely thought of what was going on with my body until 7 years ago when I started experiencing backaches. I tinkered with my workstation set up at work; I started doing a bit of yoga, then my GP sent me to rehab therapy. Nothing really helped. In 2013, I read Chris Blattman’s blog entry about the huge benefits he’d experienced in switching to a standing desk and in March 2014 I read David Roodman’s blog Stand Up for Your Health (check out all the data and graphics!). Thus inspired, I embarked on the bureaucratic journey of obtaining an adjustable desk at work; and, in the summer of 2014, the desk was set up in my office [Thank you World Bank!].

Within two weeks, virtually all my back aches disappeared. The improvement in my well-being was far greater than that however.  My body felt better across the board; I had more energy, and, I was better able to focus on what I was doing. Once I realized this, I knew without a doubt that I wanted to get a similar desk for home. I did heaps of research – naturally 😉 and ultimately purchased the Anthro Desk Elevate II (single surface). It runs about $1,500 dollars. And, it is certainly the best value-for-money purchase that I can recall having made.

 

However, there are many cheaper options. There are adjustable stands you can put on your existing desk; there are contraptions you can hang on a wall or door. If any of you haven’t taken the time to upgrade the ergonomics of your workspace, I hope you’ll do so now. [Your body will thank you]

Take time to think: are you focusing your efforts to achieve public policy goals in the right place?

So much that I’ve learned, I learned from conversations with taxi drivers. The following exchange took place in Georgetown, Guyana’s capital. The same driver had driven me to the Ministry of Health four days running, and our conversation had broadened and deepened a bit.

 

 Taxi driver: So, what was it you said you are doing here in Georgetown again?

Me: Working to identify actions and develop plans to strengthen your health system.

Taxi driver: (quizzical look in rearview mirror)

Me: We want to find ways to improve people’s health, and figure out which ones to pursue and how. And then…make that happen.

Taxi driver: Uh huh. So, why do you spend all your time talking to those folks (nod in general direction of Ministry of Health building)?

Me: ummmm.

 

I eventually came up with some reply, no doubt. But the effort to do so got me thinking about how we health policy folks make decisions about where we focus our attention and efforts. And, I realized that we often do so unthinkingly. We go where we go by habit as much as anything. Yet, over the years, I’ve learned that where you focus your attention and effort is a critically important decision.

 

I was reminded of this when I read this recent editorial Public Health Policies: Go Local! by David Bishai, Shannon Frattaroli, and Keshia M. Pollack, in the American Journal of Public Health, arguing that the US public health community should do just such a rethink. Currently, they focus the majority of their attention on the nation level. Yet,

the bulk of the money and the decisions that drive the health of the public

remain in the hands and wallets of the people and their local communities.

They note that local public health policies can make profound contributions to most of the health goals we pursue, including goals to reduce health disparities. And, these efforts can make progress even in the face of gridlock and political dysfunction on the national level.

As my Guyanan taxi driver could likely have told you:

Most of what keeps populations healthy happens in their homes, cars, communities, schools, and workplaces.

And:

What makes people sick are ideas, behaviors, chemicals, physical energy, and microbes that get close enough to penetrate the body. If you got a cold this year, you got it from somebody in the same room. Whiplash? The shockwave came from a bumper a few feet away. Hangover? Your friends may have poured and clinked the glass that gave it to you.

And, local and city policies and community level efforts can strongly influence these things. In fact,

(P)ublic health is also practiced by workplaces, neighborhood associations, schools, hospitals, health insurers, and many others with resources of time, money, and energy that dwarf national budgets for public health.

If you need more convincing of the virtues of focusing attention on the local level, Bishai et al point out that some US communities achieve outcomes rivaling those of world leaders (I’m looking at you Japan and Singapore). These outcomes depend on many factors besides public health and community efforts of course; nevertheless, spreading what nation-leading communities are doing with their public health spending, policies and activities could go a long way to closing those gaps.

What is known and practiced in the best-performing communities must be spread throughout the country.

Given that these efforts are not hamstrung by dysfunction in the national level political apparatus, I could not agree more with Bishai et al’s closing plea:

A renewed emphasis of the public health community on local action is long overdue.

I highly recommend you read the editorial; it is, alas, gated. I’m happy to email it to you.