Tuesday, June 17, 2014

Costs and Effects of a Surgial Tool

Today's Wall Stree Journal had a column that definitely attracted my attention.  The title was "Showdown for Surgical Tool."  The article was about the power morcellator.  This is a device used to "slice up" the uterine tissue that is affected by fibroids so that it can be removed through small incisions.  (I'm taking this pretty much from the article at this point.)  This provides an opportunity to perform a very minimally invasive hysterectomy.  I don't know much about this device.  I do know a think or two about abnormal uterine bleeding and hysterectomy from a project earlly in my career. 

What is interesting about this is the importance of some way of reducing the pain, discomfort, fatigue, and other symptoms associated with having fibroids and abnormal uterine bleeding.  There are medical and surgical approaches.  A traditional surgical approach is a total abdominal hysterectomy.  That, however, has some pretty negative short term consequecnes for quality of life and function.  Having a procedure that can be done in a minimally invasive way that leaves the patient with more limited symptoms and side effects seems like an ideal solution.

However, it is possible that the FDA will take the device off the market.  An extreme move done only once before according to the article.  Why?  In 1 in 350 cases (according to the article) women have a cancer that is unrecognized in advance of the procedure but that is then spread in the process of slicing the tissue for removal.  The spread of cancer can lead to a suddenly advanced case

A full understanding of this risk may change the calculus of deciding how and when to use the device.  It calls to question several things.

First, from a policy perpsecitve, what is the risk of spreading cancer this way that society is willing to accept.  As the article points out, each time the 1 in 350 becomes manifest that is someone's daugher, sistern, niece, aunt, spouse, mother, etc.  What risk is too high?  When is the risk low enough to be tolerable?

Second, regardless of what society decides, at what point would we let the patient in careful consultation with her gynecologist make a choice about what risk might be acceptable to her?  Do we allow women to make such a choice?  Can we confidently counsel them on how to make such a choice?  

Third, there are a number of solutions proposed.  Targeting women who are less likely to have cancerous fibroids.  (This would decrease the use of the device and imply that in a decision about whether to acquire and use the device there will be less marginal revenue to collect and count as a positive in the calculation in which the fixed cost is the same no matter who is treated.)  How well can we target?  For how many non-targeted women does it make it difficult or impossible to obtain a less invasive procedure.   Alternatively, the use of containment bags to limit the spread of tissue.  This would require some up front investment in teaching physicians how to use teh tehncology better and then the cost of bags.

Alternatively, the article suggests that physicians without the morcellator may turn to the much more invasive surgery.  This suggests a need to more training about other proceudres.  This is a sunk cost in the process of deciding on how to maximize the profits that could be made with or without the decision to invest.

Any solution to the issue of the power morcellator (better training, better patient choice, or containment bags) will change the economics of relevant patient care.  Women will almost certainly have at least slightly less access to the procedure until a stable equliibrium is found.  Trying to solve one problem may create another as often happens in health care.  I'm not advocating continued use.  I'm simply saying that all points and all unintended consequences must be considered.  

Monday, March 17, 2014

Mobile Application for Health Information

I saw a posting today about a new application being developed for a mobile phone that would bring together the storage of a lot of information about the phone owner's health.  What is interesting to me is to think about whether and how it would be used.  Although I am the first to admit that I probably can't anticipate all the interesting ways that it could be used and might catch on, I am pondering what seem like some of the choices that interested individuals will have to make.

First, the application has some data that can be captured by the mobile phone itself and other data that will have to be entered.  So there are a few interesting questions here.  First, for the data that the phone captures, will the user literally have to have the device on them at all times (e.g., steps during the day)?  Will that be a difficulty?  I know that I, for one, don't always want to be carrying my phone with me.  Especially when I exercise.  I'm not sure what people think in general?

Second, even for data that the phone can collect, will it collect the data automatically once the user activates the application or will the user have to activate the application each day?  Or on each "use"?  

Third, for the data that are not collected by the mobile phone itself, will there be reminders to enter the data?  If not, will people remember?

Also, for the data not being collected by the phone itself, how often will the data be needed?

Finally, will there be something that helps individuals make sense of the sum of the data?  In other words, it is certainly nice to have all the individual pieces of data.  Heart rate.  Number of steps. Height.  Weight.  And many others.  It will be nice to have this information over time.  It will be great to visualize the information over time.  But when all is said and done, does the user of the mobile phone application simply have a series of information that is interesting and that may tell the user something or is there a more powerful way of bringing all the information together so that by recognizing patterns over time and across health parameters, the user can either be reassured that everything is okay or can be told, "it's time to get things checked out" when necessary.  

I imagine that even if the technology is not there now, as the field of electronic medical records and data security continue to evolve, and a person's medical data can be integrated into an application along with longitudinal readings from the phone and a variety of other sources, and the artificial intelligence capabilities related to health monitoring continue to evolve, a very powerful platform may emerge.  

Then, the key question is who will use it?  Will people be willing to pay for it?  And how quickly will individuals act on the information they receive?  Will individuals be more or less likely to pay attention to recommendations from an application than they are to listen to their real life health care providers?  

If they are more likely is this because of the "evidence base" being used? Is it because of a trust of technology?  Is it because it is in real time?  

Figuring out whether people are more likely to take the advice and, if so,  why, will be important for figuring out how to best use a tool like the one that is being planned to improve the health of the population as a whole and not just the health of what could be a small number of really interested users.     

Friday, January 17, 2014

Pragmatic Visionary

In a discussion at my office yesterday, someone referred to me as a pragmatic visionary.  That is an interesting compliment, and I spent some time thinking about what I had said that prompted that comment and whether I would think of myself that way.  It is not the first time I have been called a visionary about the business of education and health, so maybe there is something that other people are seeing.  I certainly have never thought of myself as a visionary.  But perhaps that is just being polite and not giving myself too much credit.

In any case, the previous comment about being a visionary (to set the context was with respect to bringing cost-effectiveness analysis to eye care and to nursing.  Was I single handed responsible for it?  No, absolutely not.  But, did my efforts make a difference in bringing this new way of thinking about resource allocation, new techniques, and new language to structure resource allocation efforts in these two areas--yes.  Does that make me a visionary?  I certainly had an idea of why the new methods would be important, whom to reach, and how to communicate them. The last of those may have been the most important--storytelling.   But I'm not at all sure it makes me a visionary.

Yesterday, the conversation was one in which I simply reflected what I thought I heard a colleague saying, acknowledged that it was important, and built on it.  If there is one business skill that I have (and I really never thought of it as a business skill until I found myself in a business school), it is listening, reflecting, and improvising in the reflection.  It is the improvising that I think appealed to my colleague and led him to the visionary comment.  What did it have to do with?  It had to do with thinking about online education and the role of individual courses versus the role of the program as a whole and the role of thinking about the university-wide reputation and context in which it fit.  Most importantly, acknowledging the importance of thinking not just about the quality of each course but the bigger picture and being able to articulate that bigger picture.  Again, I'm not sure that makes me a visionary.

The pragmatic side--I kept referring back to the timeline my boss has set.  Acknowledging that while the "big picture" thinking is great, I also have to be careful to meet deadlines.

The two concepts (being a visionary whether I am one or not) and pragmatism are often at odds.  However, I think it is possible to pull them both together and make them work in harmony to lead to new and interesting ideas being implemented in a timely way.  That is the business of business in general, is it not?  To bring in new ideas, new methods, and new approaches to getting things that need to be done completed.    

Wednesday, January 15, 2014

Health LIteracy

Today, I was at a meeting at the National Institute for Nursing Research (NINR).  It was a meeting of individuals invited to discuss new research questions having to do with NINR's goal of focusing on wellness.  The meeting was described as a brainstorming session.  And at the start of the day today, the meeting was introduced as a chance to do what we always dreamed of doing in graduate school--talking about interesting research questions with colleagues.

One of the questions that we talked about was the most effective way to increase health literacy.  As I joined in the discussion about this issue, I realized how much my thinking about this type of question had changed since I had moved into my position at the Carey Business School last April.

I raised the point that health literacy is not just something that is static.  Asking a person about his or her health literacy is not like asking about their "highest level of educational attainment".  I think that the process we ended up discussing is one that could actually be quite useful:

  • Assess the current level of health literacy
  • Choose an intervention to give an immediate bump to health literacy
  • As the individual searches for new information over time provide information that is in line with the level of health literacy demonstrated at the completion of the initial intervention and continue to try to increase the literacy
  • The last point will allow the individual to learn about new conditions she has, new conditions her children may encounter, and new conditions her parents may encounter
Thus, health literacy should be something that is viewed more like a job skill set for which a person can accumulate position specific human capital rather than an educational attainment level.  My colleagues agreed with that.

I think that the key is to think about how to lay the foundation for individuals to continue to build their health literacy over their lifespans.

The key is to consider how nurses and other health professionals fit into the production of this outcome, the quantity of resources needed, and the return on investment for the individuals and society.  And to think about the business plan to make the process of assessing and improving health literacy in the population a profitable endeavor.  

Thursday, September 19, 2013

A Surprisingly Cost Saving Program--Based on Incentives

Here is an interesting story from NPR about what happens when a simple change in incentives is brought to a population.  The gist of the story is this.

In Cardiff, Wales, a lot of people were reporting to the emergency department with injuries and not reporting to the police.  The hospital did gather information about the location of the injuries and what caused them.  The leaders and people in the local area noticed how much of a toll the violence and injuries were taking on the population.  The hospital changed one thing to help police.

It did not report names.  It only reported locations of incidents and types of injuries.  The police took it from there and focused their prevention and enforcement efforts in areas that were hot spots.

The effect--spending of less than $400,000 saved over $11 million in medical and legal expenses.

That is pretty amazing.  There are a few things to think about.

First, what actually happens to the resources that are freed up?  In other words, what else are they used for?  Hopefully something more productive, but they don't really say in the story.

Second, why does such a simple incentive work?  Hospitals could not report names.  And it is somewhat amazing to think that individuals are actually sufficiently rational to choose whether to engage in violence in bars and pubs as a function of the likelihood of being caught.

Of course, this is not the first study to show that people respond to incentives--even about crime prevention.

Perhaps the idea of using simple changes in incentives with for public health measures--where the possibility of enforcement is understood, not everyone gets caught, but there are significant penalties for those who do--could encourage better public health oriented behaviors.  

Thursday, September 12, 2013

Prescribing Fruit and Vegetables

This morning I heard an interesting piece on NPR's morning edition.  The idea is that physicians in New York City can prescribe fruits and vegetables and the individuals to whom they prescribe these will get "Health Bucks" to use at the farmers' markets.  The health bucks are allocated as $1 per family member per day for up to four months.  So, a family of four would get $480 to spend at farmers' markets over four months.  In addition, they get extra education.

Is this a big deal?  Well, on a per-person per-month basis this adds $30 that can be spent only at farmer's markets.  That may be a big deal for some families.  They may be able to access quality fresh fruit and vegetables they would not be able to otherwise.  But, the $30 alone might not do much.

What would happen without information?

Are families able to make trips to the farmers' markets on a regular basis?  There is still an opportunity cost of time.

Maybe it is just enough to get them to try fresh fruit and vegetables after which they engage in better dietary behavior themselves.

There is testimony from one participant and from one physician.  Does that prove the program is successful for everyone?  Well, no program is successful for everyone.  It does offer some proof of concept.  And perhaps for $30/person/month this is a relatively inexpensive addition to a weight control program.  It would be interesting to see how well this generalizes and what options other than farmers' markets could be used when there are fewer available or the travel distances are greater.

Wednesday, September 4, 2013

Observation Status

This morning, I heard an interesting piece on Morning Edition on NPR about hospitals using "observation status" rather than admitting individuals as inpatients (the story can be found here: http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=218633011&m=218811152).  I listened with interest and thought about unintended consequences--the heart of so much of the study of health economics.

The key message here is that the government (the Center for Medicare and Medicaid Services, abbreviated CMS) has a program in which it reviews old hospital admissions (up to three years back) and determines whether the patient should have been an inpatient or outpatient.  If the patient was admitted as an inpatient and should have been (based on the CMS standards) an outpatient, then the hospital will have to repay the reimbursement it received and will likely get nothing back (according to the story).

Holding a patient in observational status (which we would generally expect would be just for a day or less, perhaps two days) avoids the determination of whether the patient needs inpatient care.  Some patients have been held in observation for even longer.  If their care is essentially inpatient and they recover, they can then be sent someplace else.  So far, if they do not need the full inpatient care this would seem to be good for CMS, good for taxpayers, and good even for the patient to the degree that the patient has copayments for which she is responsible.

The hang up (and the unintended consequence is this).  Patients are only eligible for Medicare to pay for nursing home services if they are discharged from an inpatient setting.  So, now patients who still need fairly skilled care but who do not need hospital care are not eligible for having the nursing home care covered by Medicare.  Who pays?  The family in most cases.

So, the government implemented a policy to control costs.  This led to a rational response by hospitals to avoid losses.  This leads to a lack of ability to discharge to nursing homes and/or get high quality nursing home care as patients and their families cannot pay for it.  This was not part of the intended cost control but is part of the impact.

The solution--perhaps allow Medicare to cover any rehabilitation-related care regardless of prior location.  But what unintended consequences might this have?  I will leave readers to ponder.