The Integrative Stream

In Memoriam

Dr. Daniel S. Bernstein passed away earlier this week, at 80. Dr. Bernstein was an early and vocal supporter of fluoridation initiatives, an vocal peace activist, and an incredibly influential educator in the local medical community. I knew almost none of this. Dr. Bernstein was also my primary care provider for the last six years, and an incredible example of the best kind of patient care – a model that younger doctors may aspire to but are often prevented from reaching in today’s medical environment. Dr. Bernstein would spend as much time with a patient as they needed. He never cut a corner. He reviewed your previous notes before your visit, and always followed up. When you didn’t need to worry about something, he told you why, and when you did need to worry, he told you what to do about it.

I’ve been relatively fortunate with my health, but there have been a few incidents over the years, and that’s one reason I’ve always tried have regular checkups and good doctors. I was lucky to get into Dr. Bernstein’s practice at all – I only found him on the recommendation of one of my own mentors, who had been a student of Dr. Bernstein’s years earlier, and Dr. Bernstein took me into his practice (which, given his age at the time, he had closed to new patients) as a favor. Apparently that was fairly common – he always wanted to help, and, as his obituary in the Boston Globe points out, was still inquiring after his patients from his own hospital bed.

I’m not looking forward to finding a new doctor, because I doubt that I’ll be so fortunate in the future. Primary Care is in crisis; there isn’t a single open slot in any of the hospital affiliated primary care practices at the major teaching hospitals in Harvard Medical Center. Younger doctors don’t seem to have the opportunity to practice the kind of medicine that Dr. Bernstein did. Of course, Dr. Bernstein’s personality was a bit exceptional – he was clearly more than a product of his era! – but I can’t help but see an important policy question here. How can we create a system that will make more doctors like him?

Cost and Quality

I’ve been thinking a bit about what I want to continue writing about here (I’ve also been largely on the road for the past six weeks, including my move back to Boston from Washington). Still undecided. Here’s a link about the challenge of incorporating cost into decisions about healthcare coverage.

HealthAffairs: The Difficult but Critical Step of Adding Cost

Technology Review on Next-Gen Sequencing

A disruptive technology.

Healthcare CEO Blogs, Revisited

A few days ago I wrote a post on Healthcare CEO Blogs, in which I expressed my disappointment in Steve Case’s Revolution Manifesto blog at Revolution Health. My main complaint was that it simply wasn’t all that interesting, particularly compared to two of the other (arguably) most prominent CEO blogs in the healthcare area.

In this case, disappointment was a function of expectations. I heard Hillary Clinton speak at Yale shortly after she was elected to the Senate. I know she has interesting things to say – on the dynamics of Washington, if nothing else – but she was playing things safe and her speech was boring. My reaction to Case’s blog was similar. Here’s a very smart guy, who built one of the iconic late 20th century companies and is now taking on a very complex healthcare industry. That’s a recipe for interesting discussions, provided one has the time and inclination to go ahead with actually producing the content.

I was up in Boston for meetings much of this week, and when I finally got back to Washington yesterday morning I was somewhat surprised to see a comment from Steve Case. Even more surprising was that he concurred that the blog had been a little dull of late. He also confirmed that he did, in fact, write it himself, and fair’s fair, so I apologize for the insinuation that he didn’t. Reading my RSS feed this morning, I saw not one but two new entries in the blog–and they’re increasingly interesting. I’m not so hubristic as to actually take any credit for this, since with the launch of the Revolution Health web site I suspect he has some more time on his hands.

So what’s the wrap-up here? I’m not entirely sure. The response to my post was spot on, if not necessarily economically efficient given that I’m the definition of micro market media. I’m looking forward to reading Case’s blog over the next few months, and hopefully learning something. And my advice is to follow Levy and Baker’s examples: write about whatever is interesting, wherever you have a unique insight, and without obvious spin – better to admit you can’t write about something than to write about it disingenuously (not that I’ve observed such in this case). The combination builds traffic, but it also builds trust, and trust is a vital corporate asset, especially in healthcare.

Good Healthcare CEO Blogs, Bad Healthcare CEO Blogs

CEO blogs are arriving in the healthcare space. One of the best is by Paul Levy, at Running a Hospital. Levy is the CEO of the Beth Israel-Deaconess Medical Center here in Boston. The blog is informative, candid, well written, almost obsesively frequently updated, and has caused quite a stir in the Boston healthcare community. Another local CEO healthcare blogger is Charlie Baker of Harvard Pilgrim, one of the major Massachusetts health plans. He’s posted some interesting points about healthcare costs, and the discussions in the comments have been both high minded informative. I’ve met Baker in person, and he’s an engaging speaker on issues of healthcare cost; the blog is just as interesting.

Are Levy and Baker using their blogs to drive business to their respective organizations? Not really. Levy seems to be using his as much to drive change within his own hospital (and, perhaps incidentally, the wider Boston healthcare environment). I suspect the staff members appreciate his candor. Baker’s blog is newer, but people don’t make health insurance decisions based on the CEO of the health plan; it seems that what he’s trying to do is engage constructively with the larger healthcare policy debate.

I’ve learned a lot from reading those two blogs. I’ve learned nothing from Steve Case, who is trying to lead a “Revolution” at Revolution Health. He has a blog called “The Revolution Manifesto”, which contains the occasional announcement of new features and expressions of his pride in the team that’s built the web site. I’ve learned nothing from it in the several months that I’ve subscribed to the RSS feed. I’m by no means convinced that he’s actually writing it, and I certainly haven’t come away with any new insight into the healthcare industry or his company itself. If that’s your CEO blog – let alone your Manifesto – perhaps it’s better not to bother.

Quick Updates and Brief Thoughts

Three unrelated items:

Our Personal Health Records Conference at Harvard Medical School was a big success. More soon – we’ll be posting proceedings and video from the keynotes.

Utility companies should not charge extra for online bill payment. Pepco (the DC electric utility) apparently does this. You pay more – and more than the cost of a stamp – for the privilege of saving them money. Obviously, I’m paying my DC electric bill with a good old fashioned paper stamp.

All web sites for chain stores should be able to identify mobile web browsers. When a mobile user connects, the interface should optimize for the one thing that you’re likely to be doing when accessing, say, Staples.com, from a mobile phone – finding the nearest store! Needless to say, Staples.com does not do this (and when I did find the store finder, it didn’t work). Google does a pretty good job of this, although it’s hard to get at file attachments from mobile GMail.

And that’s the wrapup for this Saturday morning, October 28th.

ISEPHR Call for Papers

The International Symposium on Electronic Personal Health Records in Trondheim, Norway has published their call for papers. I mention this because I’ll be giving a talk at the meeting, representing the Children’s Hospital Informatics Program’s Personally Controlled Health Records project.

Also on the conference front is PCHRI 2006, the Harvard Medical School Meeting on Personally Controlled Health Record Infrastructure, which I am co-chairing. It’s shaping up to be quite the Fall.

A Personal Change of Venue

I’ve been a little quiet here the last few weeks; mostly because I’ve been going flat out to get ready to relocate to Washington, DC. I haven’t mentioned it up to this point because I was waiting for the final confirmation paperwork, and you never really know with government until things have settled down.

So here’s the big announcement: I’m taking time off from MIT Sloan and from the Harvard-MIT Division of Health Sciences & Technology to join the staff of the Office of Policy at the Centers for Medicare and Medicaid Services in Washington, DC. Specifically, I will be focusing on healthcare information technology and its implications for the present and future of Medicare and Medicaid. I start on July 23rd.

Those who know me well are aware that I’ve already had a fascination with government. While, this time last year I did not expect to be in a government position right now (certainly not an extended duration one), I’m pretty pleased that everything worked out.

As for the implications for this blog: I’m honestly not sure. The main issue is that I may have to scale back my discussion of healthcare IT issues and possibly of broader public health policy issues as well. It goes without saying that anything discussed on this blog does not represent the opinion of the United States Government, nor does my hiring represent an endorsement of anything I may have written here to date. There are very few federal employees who maintain active web sites, which means there are few models. I will be consulting with the ethics office over the next few weeks to determine what the boundaries are. Practical considerations may play just as much of a role, in which case the posting schedule here may shift to less frequent, longer articles.

As for the process of moving? Not fun. Not fun at all. I’ve managed to avoid moving more than a 2.5 hour drive at a time for my entire adult life, and over the last five years I’ve bought a lot of furniture. The truck comes tomorrow, and am I ready? No.

Online Physician Visits

This is a critical trend, with implications for cost containment, chronic care providers and software vendors. With insurers reimbursing for online consultations the economics change for everybody.

ContraCostaTimes.com | 06/08/2006 | The doctor will see you now — on your laptop

HIPAA Unenforced

Washington Post: Medical Privacy Law Nets No Fines

More on Health Insurance Payments

Here’s the AHIP report on electronic claims (pdf). It includes some different numbers on the cost of claims: a clean electronic claim costs 85 cents, a clean paper claim costs $1.58, and a pending claim requiring manual review costs about $2.05 (it isn’t clear whether or not that last average is for paper, electronic, or both). Absolute values are a lot less than the numbers I had, but the proportions are about right and there’s still a lot of cash on the table.

Online Claims Up

The New York Times reports that as of this year, three-quarters of insurance claims are made online (NYT link, registration required). That’s up from 44% in 2002.

And now, data I can’t source properly: an electronic claim costs $8 to process. That sounds like a lot, until you realize that a paper claim costs $16 (this is from an IBM presentation I recently attended). Surprisingly, twenty minutes of web surfing didn’t produce a good number for total health insurance claims on an annual basis. On the other hand, WellPoint alone processes 2.4 billion claim line items a year, according to this article on payer performance. WellPoint is just one insurance company. Assume 10 line items a claim; that’s 240 million claims a year for a player with relatively small market share (Medicare alone covers 50 million seniors).

Even without making the math fuzzier, there’s still a tremendous amount of money left on the table.

Health IT Microeconomics

More insurers are reimbursing doctors for online care. Cost issues have kept small physician offices from adopting sophisticated health information technology. And that’s no surprise: clinical systems are complex, and small medical practices are under increasing financial pressure. That means seeing more patients more efficiently and-surprise!-electronic medical records and related tools don’t always mean a quicker visit. Often a better visit, but not a quicker one.

Insurance companies control the final line of incentives for doctors and hospitals to invest in process improvement. If doctors can get paid for an online visit, even if only enough to cover costs, they’ll do a lot more. And since an online visit is less costly for all concerned, everybody wins. Patients win most of all, especially considering the noneconomic costs of going to see your physician. Those costs are substantial – travel time, lost work, gas.

WSJ.com – Hospital Link Could Catch Outbreaks Early

Subscription required; writeup of the CDC’s BioSense system.

WSJ.com – Hospital Link Could Catch Outbreaks Early

Carnival of Biotechnology

Carnival of Biotechnology. You can never have too many. The first edition. Not that much in this week’s edition, but it’s a good idea.

Health Wonk Review

Managed Care Matters has the
first edition of the Health Wonk Review, a new biweekly carnival of blog posts on health care policy. Hopefully this will pick up some steam: it’s a worthwhile project.

Procedure Price Escalation

And as I continue this morning’s round of the medical blogs, Kevin, M.D., discusses the decline of the physical exam in favor of more clinically clear-cut diagnostics. Lawsuit survivability is a big part of this, and it’s certainly affecting health care costs. Comments on the post vary from interesting to fairly simplistic.

Earlier this week I was at a talk given by Harvard’s David Cutler, focusing on the relative importance of medicine in healthcare. The topic sounds a little odd, but it’s if you think about it, it’s not: only in the last thirty to fifty years have medical advances been the main driver of increased life expectancies. They played a role prior to that, but public health and rising economic conditions played a much larger one. Sewers were, perhaps, the statins of their day. And when you look at things in this context, those extra years of life expectancy are getting a lot more expensive.

Danish Cartoons and Global Medicine

MedPundit writes of boycotts of European drugs in countries angered by the now-infamous Mohammed cartoons. Patients suffer.

Medical Digital Divide

The Boston Globe reports on the rising gap between IT-haves and IT-have-nots. A good explanation of why electronic health record adoption has been as low as it has been.

Biomedical Enterprise Program in FT

My graduate program, the MIT Biomedical Enterprise Program, is the focus of an article in the Financial Times today. My friend Rupa (who is also here in New Zealand this month, although working with another firm) gets the lead mention. I haven’t done my autopsy yet. Next year.

The BEP is a young program, so it’s nice to see the profile rising.