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Middle Age Can Be Hazardous to Your Health

The Healthcare Blog - Thu, 11/12/2015 - 13:12

Despite the many flaws in our healthcare system, we could always point to data showing that over the last few decades we were living longer and healthier lives—even if not quite as long and healthy as our contemporaries in many European and some Asian countries.

It now appears that’s no longer true for one segment of the U.S. population.

I’m talking, of course, about the surprising findings released last week that the death rate among non-Hispanic white men and women ages 45 to 54 increased from 1999 to 2013 after decreasing steadily for 20 years, as it did for other age cohorts and ethnic groups.

The rise was small in absolute terms—half a percent a year—but it was a relatively sharpreversal in direction from the average 2% a year decline in death rate from 1978 to 1998.  Moreover, this population experienced an increase in non-fatal diseases and conditions, too (called morbidity).

For both death rates and morbidity, the reversal occurred in all income and education brackets in the 45-54 age cohort, but it was most pronounced among those with lower incomes and less than a college education.

The researchers found that no other developed country experienced a similar reversal.  And blacks, Hispanics, and those aged 65 and above in the U.S continued to see death rates fall in the period examined.

The bottom line in terms of overall impact: If the death rate for white 45−54 year olds had continued to decline at its previous (2%) rate, half a million deaths (and these are premature deaths) would have been avoided from 1999 to 2013. That’s comparable to lives lost so far to AIDS, the author’s say. It’s also on a par with the increased death rates and lower life expectancy in Russia in the 1980s and 90s.

What’s going on?! The researchers didn’t mince words in their published article or in media comments: this unwelcome turn of events is attributable almost entirely to “deaths from distress and despair…both economic and psychological,” as co-author Ann Case of Princeton University put it in an NPR radio interview.

Namely, the rise in death rate, they found, was triggered by drug and alcohol poisonings, suicide, chronic liver diseases and cirrhosis of the liver. Likewise, the increase in morbidity reflected a rise in alcohol and illicit drug use; abuse and misuse of prescription drugs; psychological distress; physical problems and pain (neck, facial, joint and back, and sciatica), and difficulties with the activities of daily living.

I’m sure the sophisticated THCB readership can pretty much deduce the confluence of factors that precipitated this reversal, though few of us might have predicted it would be so intense or so specific to the white middle-aged:

  • The erosion of the manufacturing base and loss of blue-collar jobs (down from 28% of jobs in 1970 to 17% in 2010, and still declining), and the loss of rural jobs
  • Wage and income stagnation in the low- and middle-income groups
  • Income inequality and economic insecurity
  • The great recession
  • The decline of the stable 2-parent family (the percent of single white mothers rose from 18% in 1980 to 30% in 2010 for those with no college degree)
  • People giving up on being in the work force
  • Shifts in social trends leading to more isolation andloss of community
  • The ready availability, overuse and abuse of both prescription and illegal drugs, especially narcotic painkillers and heroin (opioids)
  • Poor diet, physical activity and health and lifestyle habits (despite years of public health messaging)
  • Asuboptimal and dysfunctional mental health system and poor access to mental health care and substance abuse programs
  • Rising out-of-pocket healthcare costs for people with inadequate or no health insurance, leading them to postpone or forgo treatment

This new-found trend represents a public health failure and a failure of our healthcare safety net.  In particular, it’s yet another marker of dismal mental healthcare access and inadequate community-based substance abuse programs.  If not addressed, the trend bodes ill on many fronts.   For one, this cohort will age into Medicare in worse health than the current elderly.  That will cost money.  The reversal is already eroding productivity, the authors suggest.

They don’t pull punches in other conclusions: “Addictions are hard to treat….so those currently in midlife may be a ‘lost generation’ whose future is less bright than those who preceded them.”

That less prosperous future is, of course, also forecast for today’s urban black youth, new retirees, and even segments of the millennial generation—due to some of the same cultural, social and economic forces.  Healthcare professionals, administrators and policy wonks can’t solve all the above-mentioned underlying problems but it seems to me that they (we) have a responsibility to advocateharder for solutions.

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.

Categories: OIG Advisory Opinions

Physician Disrupt Thyself

The Healthcare Blog - Thu, 11/12/2015 - 11:50

(Stepping away from health policy and business this week, a quick post on alternative careers in medicine).

Wrapping up a great week spent with emergency medicine friends attending this year’s American College of Emergency Physicians national meeting in Boston. Over the course of a few receptions and dinners, more than one old friend has stopped to ask me about how I made the decision to step away from caring for patients in the emergency department and into a nonclinical role at a progressive startup healthcare company. A few friends confessed that they love the idea of getting their hands dirty fixing a broken healthcare system– but don’t know where to begin.

I have a very limited perspective and I’m no expert on career pivots. But I often look to an article I came across a few years ago, written by Whitney Johnson in the Harvard Business Review. Her article is called Disrupt Yourself.

In the piece (and later in her book) Johnson argues that people can successfully transition into satisfying roles in new businesses but often need to “disrupt” themselves and their current careers. This disruption is needed because moving to another job or field (even one adjacent to the one you’re in) is hard. I think that this is particularly true in medicine where the time and money needed to become a doctor creates incumbents, inherently resistant to change.  Physicians are, by nature of our training and regulation, IBMs and Microsofts. We are slow to change. We can plateau.


She writes:

If as an individual you’ve reached a plateau or you suspect you won’t be happy at the top rung of the ladder you’re climbing, you should disrupt yourself for the same reasons that companies must.

Johnson references Clayton Christensen, who is the father of disruptive innovation, which is the theory that the most successful innovations create new markets and value networks. She believes that the same principles hold true for positioning yourself in the career market:

I believe that disruption can also work on a personal level, not just for entrepreneurs who launch disruptive companies but for people who work within and move between organizations. Zigzagging career paths may be common now, but the people who zigzag best don’t do it randomly.

Johnson identifies four principles for folks looking to translate their skills into a new type of work. She writes that they need to:

  1. Target a needthat can be met more effectively.
  2. Identify their disruptive strengths.

Don’t think just about what you do well—think about what you do well that most others can’t. Those are your disruptive strengths.

  1. Step back (or sideways)in order to grow

An individual’s well-being depends on learning and advancement. When organizations get too big, they stop exploring smaller, riskier but perhaps more lucrative markets because the resulting revenues won’t affect their bottom line enough.

  1. Let their strategy emerge.

Because we’re not following traditional paths, we can’t always see the end from the beginning. As John D. Rockefeller wrote, “If you want to succeed, you should strike out on new paths, rather than travel worn paths of accepted success.”

Marc is a doctor and healthcare executive living in Boston. He is a fellow of the American College of Healthcare Executives and the American College of Emergency Physicians.

Categories: OIG Advisory Opinions

Can Community Organizing and The “third place” Improve Public Health?

The Healthcare Blog - Thu, 11/12/2015 - 11:38

The majority of health problems in modern developed countries are self-inflicted, the results of lifestyle choices. These problems don’t respond to a pill–or even to bariatric surgery. Moreover, the medical profession hasn’t found ways to change lifestyle.

For instance, one study found that only one of six overweight adults in the US have sustained a weight loss–and that was an improvement over other studies. Another site claims that 90-95% of all dieters regain their weight within five years. It’s encouraging to note an 80% improvement among people with obesity who get treatment–but the source doesn’t say what “treatment” is. It apparently goes far beyond advice and Weight Watchers–so only 10% of obese Americans get treatment in the first place.

Health problems are killing us, and bankrupting us along the way. It’s well known that a tiny percentage of patients generate the most treatment and the highest health care costs, as Atul Gawande pointed out in a famous New Yorker article.

Of course, lifestyle doesn’t lie behind all hot-spotters (for some we can blame birth defects or other debilitating accidents, and for others we can blame over intervention in dying people), but a lot of them just just exhibit exaggerated versions of the common behavior problems most Americans face: bad eating, drug use, lack of exercise, etc.

A number of months ago, I met with a leading public health expert in Massachusetts. After I walked down to Arlington’s premier professional rendezvous, the Kickstand Cafe, we talked over oatmeal with nuts and fruit about behavior change, public health, and patient engagement, which I prefer to call patient empowerment–or as he put it, “patient activation” (which sounds to me opening an account at some business).

The expert and I shared another connection besides our mutual interest in health. We are active members of the Greater Boston Interfaith Organization, a 20-year-old community organizing group that is part of the Industrial Areas Foundation founded by Saul Alinsky in 1940. So we started asking each other what a community organization could do to improve its members’ health. GBIO wasn’t the first to join the universal coverage movement, but the muscle of its 50 congregations and 10,000 members became key to passing Massachusett’s 2006 health care act, often called “Romneycare” and the basis for the national Affordable Care Act. I personally lobbied a leading State Senate member and sat in on a hearing where Mitt Romney defended his individual mandate.

Since passage of the law, we’ve built relationships with government and industry figures and helped create the policies that made universal coverage universally popular in the state.

However, rising costs are still a problem. The state also has a long way to go to address key behavior changes in the population.

With the major features of reform in place, GBIO has been sidelined to a relatively reactive role, such as protesting a merger involving the Massachusetts mega-provider, Partners Health Care. We’d like to play a constructive role as well.

The key may be support and community–what GBIO is built on, and what sick people also need. Many clinics create support teams that do things such as send text messages to encourage healthy behavior among patients with chronic conditions, and mobile devices make patient monitoring feasible, but there are limits to the level of engagement clinic staff can create.

Other programs involve family members, whose intense relationships can make their messages powerful. But we can’t always depend on family members: they may be busy, disengaged, overwhelmed by the patient’s needs, or burned-out after years of failure to improve. They may be addicted to the same unhealthy food choices or behaviors that are making the patient worse, and perhaps even enable those behaviors. (See the movie “Fed Up” and consider the families’ roles in the cases they document.)

So is there a role for the community? There are many calls in the public health sector for community involvement, like an emergency physician’s observation that health is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. One objective of an ONC six-year Federal health IT strategic plan is to “Protect and promote public health and healthy, resilient communities.” The idea of making a whole town responsible for its residents health makes Esther Dyson’s “Way to Wellville” intriguing, even though it’s a rather mixed bag of disparate elements.

The religious centers, labor unions, and other organizations making up GBIO represent the most important instances in the US of the “third place” described in the classic Ray Oldenburg book, The Great Good Place. People in these places step outside the roles and constraints they deal with at work and in the home. They take on new roles–and perhaps we can make those healthy roles.

One model is provided by a GBIO initiative on debt. Like most of our activities, the initiative was launched after hundreds of discussions among congregants about the problems that have the biggest impacts on our lives. Numerous political campaigns, of course, have been conducted around debt–student loans are a highly publicized example–but GBIO started with a personal program called Moving from Debt to Assets. Through courses led by local financial experts, support groups, and other contacts, the program helped 875 people extract themselves from debt and start saving money.

What could congregations do to support people whose problems are with their bodies rather than their finances? Could peer support, regular guidance, and even a generous dose of religious motivation overcome the dismal statistics for behavior change? Here are some ways community organizations and their member congregations could make a positive impact on their members’ health:

  • Invite speakers to congregational events and even services to describe paths to better health, along with recent discoveries.
  • Organize peer support groups. Some expert guidance may be necessary here to guarantee the privacy of what people say.
  • Carry out group discussions in the classic community organizing manner to discover local health problems affecting the congregation–such as trucks idling at a construction site, or a lack of fresh vegetables and fruits in local stores–and organize for change.
  • Advocate for patient access to records, the provision of coordinated care teams to patients who need them, and other improvements in provider behavior.
  • Use the network of “caring committee” members to help individuals find doctors, and accompany those who need help with translation, medical terminology, or understanding care plans.
  • Encourage the use of appropriate health IT tools such as educational apps and sensors, and provide training.
  • Create a healthy environment within the congregation itself, such as an examination of the food served at community events.
  • Draw on religious traditions and texts to provide inspirations that link health to leading a good life.

Both top-down change (regulation) and bottom-up change (patient empowerment) are key ingredients to improving health care. But something critical also lies in between–community action. Proven community organizing techniques and advocacy among institutions in the patients’ lives might make all the difference.

Andy Oram is an editor at O’Reilly Media.

Categories: OIG Advisory Opinions

What Doctors should Know when Joining a Startup – Five Key Books

The Healthcare Blog - Thu, 11/12/2015 - 11:35

What should doctors know before joining a startup? I don’t know if these were questions medical school graduates in the Bay Area asked themselves as they opted to join a startup rather than completing their medical training in residency programs. These new doctors felt they could make a bigger impact on patient care by leaving the system and its current status quo.

Why not? In the Bay Area, small startups and former startups like Facebook, Google, and Apple are literally blocks away from academic medical centers. Everyone knows someone working at a startup. At a healthcare innovation summit, Vinod Khosla, co-founder of Sun Microsystems and venture capitalist reassured technology entrepreneurs that the opportunities to disrupt healthcare were tremendous. After all,

“Health care is like witchcraft and just based on tradition.”

Khosla encouraged attendees to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists. Disruption required having an outsider point of view. Khosla highlighted how CEO Jack Dorsey of Square was able to disrupt and provide services more cheaply than the traditional methods of the electronic payment system accepting Visa and Mastercard because only 2 percent of the employees at Square ever worked in the industry.

Former Executive Editor of WIRED Thomas Goetz interviewing venture capitalist Vinod Khosla

There is the lingering perception that technology can make health care cheaper, more accessible, and better without physician insights. Yet there have been few public successes so far. In an interview with Malcolm Gladwell, venture capitalist Bill Gurley seemed resigned to the fact that finding such a startup to fix healthcare will not happen.

Yet, I believe there are opportunities for startups to help. For healthcare to be disrupted, doctors and Silicon Valley need to collaborate. Each group brings valid and important points of view that the other cannot fully understand simply because you don’t know what you don’t know.  For doctors joining a startup, add tremendous value by understanding the challenges the healthcare system faces as well as the challenges and mindset of a startup. Here are five recommended books to get you started.

What is Disruption? The Innovator’s Prescription

You hear how startups will disrupt the status quo. Who came up with this? Harvard Business School Professor Clay Christensen has often been credited with the concept of a disruptive innovation. A disruptive innovation is a product or service that not very good initially. It serves a market or need that is currently ignored by incumbents. Over time the disruptive innovation gets so much better that it serves larger markets or needs that it overtakes the incumbent companies. At this point it is too late for the incumbents to respond. An example of such an disruptive innovation might be Apple’s iPhone where much of the initial functionality has now become so robust that incumbents creating digital camera, GPS, camcorders, or laptop computers are in trouble.

Christensen’s book, The Innovator’s Prescription: A Disruptive Solution for Health Care, is the best book on how disruption in health care might occur. By looking at other industries where initially products and services offered were “so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them” and how over time everyone now had access to telephones, computers, and airline travel, the book provides a framework on how that will happen in health care.

Anyone wanting to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to add this book to their list of must reads.

Zero To One: Notes on Startups, or How to Build the Future

The Hard Things About Hard Things: Building a Business When There Are No Easy Answers

Written by entrepreneurs, Peter Thiel and Ben Horowitz respectively, these books provide an insider’s perspective on both the promise and perils of being in a startup. Venture capitalist Peter Thiel was the co-founder and CEO of PayPal and founder of Planitir. Thiel believes technology can solve our problems and the importance of using the strengths of technology and people to make an impact.Zero to One: Notes on Startups, or How to Build the Future notes there is only one moment in time when something is invented and you go from zero to one. The creation of Google was such a moment.

If Thiel’s book captures the optimism of a better future, Horowitz’s book details the gritty realities of a startup CEO in The Hard Thing About Hard Things: Building a Business When There Are No Easy AnswersVenture capitalist Horowitz was CEO of Opsware.  He pivoted the business multiple times when things looked bleak, found capital during the worst economic crisis since the Great Depression when everyone thought he was insane, and led the company through multiple layoffs before successfully being sold. A sobering yet incredibly important read, Horowitz shatters the allure, mystic, and promise of startups and replaces it with the stark frankness that the world is competitive and startups are fragile and the path to success difficult.

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

Understanding the current healthcare status quo is important if one is to understand the variation in medical care and outcomes. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer is the best book to quickly get you up to speed on why we are the most expensive in the world and the worst at keeping us healthy. Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive. Learn what you are up against if you plan on disrupting healthcare.

Teaming: How Organizations Learn, Innovate and Compete in the Knowledge Economy

Doctors don’t work well in teams. This was outlined by New Yorker writer, best-selling author, and surgeon Dr. Atul Gawande  in Cowboys and Pit Crews. Yet it is teamwork across disciplines that matter in a startup. Here is where Harvard Business School Professor Amy Edmonson’s Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy is helpful.  To maximize learning, conflict and failure are necessary for teaming to be successful. Successful teaming requires an environment where it is psychologically safe to speak up, which is not typically true in a hospital environment where a strict hierarchy still pervades. Edmonson highlights how individual and organizational psychology, the reality of hierarchical status, cultural differences, and distance can and do separate team members which can prevent successful teaming. Leaders can close these gaps by understanding the existence of these obstacles and by adapting their leadership style to support and facilitate teaming successfully. She gives plenty of examples where teaming went well and not so well (the “impossible” rescue of miners in Chile and space shuttle Columbia tragedy).  Learning thoughtfully from these failures and framing them as essential for continuous improvement and innovation is key for organizations to benefit from teaming. So by understanding these dynamics, you can determine whether your startup has the dynamics it needs to be successful and how to lead one.

There you have it. Five books. Five perspectives. Good luck! I can’t wait to hear what you come up with!

Davis Liu, M.D., is a practicing board-certified family physician with the Permanente Medical Group in Northern California since 2000

Categories: OIG Advisory Opinions

ICD-10 Transition Likely Bumpy Into Early 2016

Medical Coding News - Wed, 11/11/2015 - 09:38

The U.S. health care system began using the International Classification of Diseases 10th edition on Oct. 1. Login to Read More

The post ICD-10 Transition Likely Bumpy Into Early 2016 appeared first on MedicalCodingNews.Org.

Categories: Healthcare News