As Walmart Buys Online Retailers, Their Health Benefits Suffer

In little more than a year, Walmart has spent nearly $4 billion acquiring e-commerce companies with thousands of workers. Last month, many learned that their potential out-of-pocket costs for medical expenses would increase in 2018 at a rate far exceeding the overall rise in health care costs — reaching thousands of dollars in many cases.

Health care benefits tend to be harder to come by in retail than in any other industry, with just over half of all retail employees eligible for company plans, versus more than 90 percent in manufacturing, according to a survey this year by the Kaiser Family Foundation. Retail workers also opt into their company plans at a far lower rate than any other industry’s workers, possibly suggesting that the insurance is not very attractive or affordable even when companies do offer it.

The abstract to the KFF survey reads:

This annual survey of employers provides a detailed look at trends in employer-sponsored health coverage including premiums, employee contributions, cost-sharing provisions, and employer practices. The 2017 survey included more than 2,100 interviews with non-federal public and private firms.

...The 2017 survey includes information on the use of incentives for employer wellness programs, plan cost sharing, and firm offer rates. Survey results are released in a variety of ways, including a full report with downloadable tables on a variety of topics, summary of findings, and an article published in the journal Health Affairs.

What used to be employee-based insurance, and I'm sure you hope to have such insurance in your own workplace, is no longer affordable by many employees.

Banner Health hits snags migrating two hospitals from Epic to Cerner EHR

As I continue to read your blogs and comment on your second drafts, I came across this article in Healthcare IT News (from a Kaiser News link).  It speaks to many issues we discussed, including how difficult it is to switch to new EHR systems, and that long lines persist even in the US (and not just Canada).   The picture posted on the article should look familiar.  I love this quote.  It masks the real issues underfoot, don't you think?

While EMR implementations are always challenging, our specific challenges have included issues with slowness and workflow delays that have caused longer than normal patient wait times.

The short article chalks it up to implementation issues that will soon be remedied.  "Banner’s chief clinical officer John Hensing, MD, told the Arizona Star that the Cerner migration has thus far been a 'painful period,' but added that performance degradation can happen when switching to any new application because transitioning systems is a complex undertaking."

Really?  So we can expect smooth sailing soon?

Watch the Backstory of the American Opioid Story

I posted the reading in D2L and in an earlier post on this blog about the Sackler family from the New Yorker article (and we heard from Steven May who is also mentioned in this article).    Here is a link to the video of the backstory from Patrick Radden Keefe, the author of the story.  It is pretty grim for a 6-minute video.

Watch this video on The Scene.

More on Purdue and the Sackler Family

Regarding the question regarding the board of directors at Purdue.  In the New Yorker article from the end of October about Sackler family, it starts like this:

Andrew Kolodny, the co-director of the Opioid Policy Research Collaborative, at Brandeis University, has worked with hundreds of patients addicted to opioids. He told me that, though many fatal overdoses have resulted from opioids other than OxyContin, the crisis was initially precipitated by a shift in the culture of prescribing—a shift carefully engineered by Purdue. “If you look at the prescribing trends for all the different opioids, it’s in 1996 that prescribing really takes off,” Kolodny said. “It’s not a coincidence. That was the year Purdue launched a multifaceted campaign that misinformed the medical community about the risks.” When I asked Kolodny how much of the blame Purdue bears for the current public-health crisis, he responded, “The lion’s share.”

Although the Sackler name can be found on dozens of buildings, Purdue’s Web site scarcely mentions the family, and a list of the company’s board of directors fails to include eight family members, from three generations, who serve in that capacity. “I don’t know how many rooms in different parts of the world I’ve given talks in that were named after the Sacklers,” Allen Frances, the former chair of psychiatry at Duke University School of Medicine, told me. “Their name has been pushed forward as the epitome of good works and of the fruits of the capitalist system. But, when it comes down to it, they’ve earned this fortune at the expense of millions of people who are addicted. It’s shocking how they have gotten away with it.”

Read more... 

Pulitzer Award on Opioid Abuse in West Virginia

Here is a series of articles related to our topic this week. Rather than add it to our readings, I thought we could comment here. Click on the author and Gazette-Mail link for access to the three articles. I'll post some thoughts below.  But you can do the same.

INVESTIGATIVE REPORTING

Photo

Mr. Eyre (pronounced AIR), 51, won the award for a series of articles about the opioid abuse epidemic in West Virginia. Mr. Eyre, the paper’s statehouse reporter, began his multipart series with these words: “Follow the pills and you’ll find the overdose deaths.” It took Mr. Eyre years to acquire the documents most important to his reporting, and he did it “in the face of powerful opposition,” according to the Pulitzer citation. A lawyer defending a drug wholesale company said that it was vital to protect crucial court records “from the intrusive journalistic nose of the Gazette-Mail.”

The series uncovered how small towns of 392 people were devastated from opioid overdoses.  Look at the data, read the series, and comment.  Follow the link:

Eric Eyre, The Charleston Gazette-Mail

Opioids: Last Week Tonight With John Oliver (HBO)

I saw this last year (Oct. 2016), and maybe you did, too.  The language is explicit, and views of addicts and what they do to get their drugs.  But it's relevant to our week of Pharma and Addiction conversation.  He interjects his strange humor as he gets to the main points, which are important, especially Purdue's marketing of OxyContin.

Personalized Diagnostics

Here is another example of what we talked about today: Personalized Diagnostics, which is the result of research to create drugs to treat a large variety of cancers. After all, cancer is not a single disease, it is a collection of diseases.  Every cancer is different because it is caused by a different mutation. BRCA1 gene mutation primarily causes Ovarian cancer while KRAS gene mutation primarily causes Colo-rectal cancer. But it is more complicated that.

A single gene can have mutations in thousands of different places. Some mutations have shown no effect in cancer development, whereas other specific location mutations wreak havoc on the body.  For example, take a look at the below image. Though BRCA1 mutation causes Ovarian cancer, specific location mutation in the same gene can result in other forms of cancer. Similarly, mutations in genes other than BRCA1 can lead to Ovarian cancer.

What does this information mean?

This means that there is an astronomical number of mutation combinations possible, and we are barely scratching the surface of targeted cancer therapies.  For simplicity, say MutationA responds to Drug1 and MutationA has no response for Drug2, we can then say that Drug1 is the preferred treatment for MutationA. This means that there is potentially lot of trial and error to understand which drug works for which mutation.  Cancer research institutes have been collecting this information for a long time, with thousands of records of medical literature for cancer and its treatments. Yet we have more to work towards better targeted therapies.

Finding the gene is inefficient

Though we may have information on the best recommended therapy for a cancer, targeted therapy would mean that we need to understand the composition of the cancer. The current scenario involves the oncologist conducting a tumor biopsy followed by a single gene mutation test. Once the mutation is understood, the oncologist relies on his/her expertise or references current medical literature for the best targeted treatment. This would mean hours spent on combing through information.  Then, we have to ask, is this the best possible scenario?  What if the single gene sequencing reveals no mutation and the tumor is caused by another gene?  Gene sequencing is expensive, now which single gene mutation test should the oncologist order?  Even if sequencing a gene is affordable, running tests one gene at a time to find the mutation can be costly for the patient's life, as time is of the essence when dealing with cancer remedies. 

Making cancer treatment personal

Personalized Diagnostics can help overcome the inefficiency faced by care providers today. I'll give a brief overview:

A collaboration between IBM Watson, Quest Diagnostics, and Memorial Sloan Kettering has facilitated in the development of the Comprehensive Cancer Test called OncoVantage™. Each organization is responsible for delivering an integral component of Personalized Cancer Diagnostics. A simple diagram below shows the role of each player.

With OncoVantage™, oncologist are able to run mutation analysis for 34 genes at the same time for a considerably reduced cost. Additionally, the oncologist saves time with the report being presented with the latest medical literature referencing all the mutations identified in the tumor.

Quest Diagnostics

OncoVantage™ is a $3,000 test using the latest genome sequencing to analyzing mutations in 34 genes in one complete sequencing from a sample of the tumor biopsy. The mutation analysis along with the complete sequencing report is shared with IBM Watson.

IBM Watson

Using advanced computing power, Watson cross-references the mutation analysis with the medical literature. Its advanced cognitive system is able to present a weighted analysis for each mutation observed and present a comprehensive report.

Memorial Sloan Kettering

MSK is one among the many partnership with cancer research institutes that IBM Watson has leveraged to fight against cancer. MSK with 130 years of excellence dedicated to cancer has a real-time functioning database for cancer research called OncoKB. This vast repository provides data which include treatment methods and its effectiveness.

Oncologist can now download this report to make informed decisions. The report also provides current clinical trials which aids the oncologist to recommend programs which the patients can participate.  Saving time and offering a precise treatment comes from an enhanced diagnosis. Personalized Diagnostics still has a long way to go, but this collaboration shows us the promise of the future of targeted therapies, not just for cancer, but potentially all diseases.

Cleveland Clinic Grapples with Changes in Healthcare

While the renowned Cleveland Clinic, one of the most respected nonprofit health systems in the nation, has traditionally relied on its ability to provide high-priced specialty care, the system, along with every stand-alone community hospital and large academic medical center, is being forced to remake itself. Patients are increasingly seeking care outside the hospital — in a family health center, a doctor’s office, a drugstore or at home. Medicare and other insurers are moving away from volume-based payments to new models, to pay less for better care.

Dr. Delos M. Cosgrove, a 74-year-old former heart surgeon who took over as chief executive about a decade ago, likens what is happening in health care to the upheaval decades ago in the steel industry, where companies disappeared when they were unable to respond to change and new competition. “The disruption is going to happen,” he said. As an inevitable shakeout takes place among health care institutions, a look at how the clinic is responding underscores the industry’s challenges and the flurry of activity taking place as institutions try to adapt.

https://www.nytimes.com/2015/03/18/business/cleveland-clinic-grapples-with-changes-in-health-care.html

We briefly talked about these different medical options for patients.  It's interesting to read how Cleveland Clinic is responding to the "disruption."  Thoughts?

Economic Rules of the Dysfunctional Medical Market

At the end of Chapter 1 of E. Rosenthal's book, American Sickness, (on D2L, Week 3), she sites these economic rules of the dysfunctional medical market.  I post them here for review:

1. More treatment is always better.  Default to the most expensive option.

2. A lifetime of treatment is preferable to a cure.

3. Amenities and marketing matter more than good care.

4. As technologies age, prices can rise rather than fall.

5.  There is no free choice.  Patients are stuck.  And they're stuck buying American.

6.  More competitors vying for business doesn't mean better prices; it can drive prices up, not down.

7.  Economies of scale don't translate to lower prices.  With their market power, big providers can simply demand more.

8. There is no such thing as a fixed price for a procedure or test.  And the uninsured pay the highest prices of all.

9.  There are no standards for billing.  There's money to be made in billing for everything and anything.

10. Prices will rise to what the market will bear.

Cleveland Clinic and Patients First Case

Cleveland Clinic's overall strategy is to create measures such as improving structure, processes, and outcomes of patient care that would push Dr. Cosgrove's central message, "Patients First!"

The Clinic is doing well in having this integrated electronic medical record system that basically records patients reports and allows physicals to review the care being delivered to their patients. It had also enable information technology to support any measurement, learning, and improvement by teams.

The clinic has also made measures such as shared savings that would enable the Clinic to achieve cost reduction and this payment reform would then allowed teams to manage care paths more effectively.

I think that the overall message of "Patients First" is really good. I also like the idea of having an online portal (Open notes) where patients are able to review their sessions with doctors or physicians as well as their health records online. A distant relative uncle of mine past away in Malaysia from some illness, that was only discovered after transferring from an Adventist hospital to another clinic. And by the time, it was discovered it was already in the last stage of life. What frustrated my family relatives was that the doctor from the Adventist hospital refuses to provide the new hospital of my relative's health records, and any treatment prescriptions that they have provided to him in the months he stayed at the Adventist hospital. It delayed my uncle's medical treatment, and like Regina's husband, my uncle wasn't able to make it through. If there was something like Open Notes in Malaysia, or if the doctor of the Adventist hospital would be more cooperative, and would listen to my uncle's story more, my uncle would have gotten better treatments and he would have lived.

I really feel like it would help make patient care more efficient and easier for patients to get health care in a different area. But there's still the question of how much customer services should healthcare industries provide.

Cleveland Clinic & Patients First

1. Value for patients seems to always have been at the heart (no pun intended) of Cleveland Clinic’s objectives. It began almost 100 years based on the principles of cooperation, compassion and innovation. Everything they’ve done since then has seemingly kept this in mind and they also implemented strategies for perpetual growth. One example of this involved becoming the most frequent provider coronary artery bypass operations (1970’s) while at the same time becoming the first patient outcome registry where they would contact patients, at home, post-surgery to see how they were doing. This commitment to quality continued through the early 2000’s when they adopted a focus on evidence-based practices (who would have thought). This also coincidentally aligned with their goals of growth in helping to provide compliance for reasons of accreditation.

The year 2004 also showed to be a pivotal moment in the company with their development of the motto “Patients First”. At the heart of this was creating an atmosphere of multi-disciplinary teams amongst all the different medical disciplines in the Clinic, “upsetting traditional organizational hierarchies”. Different institutes were created under the umbrella of Cleveland Clinic with this multi-disciplinary approach at the heart of it. The idea of evidence-base approach continued in this as the Clinic’s head, Dr. Delos Cosgrove, implemented measurements for improving “structures, processes and outcomes”. The Clinic also invested heavily in information technology to help in these measurements and allow patients full transparency of their medical records.

2. Measurable results showing that the policies Cleveland Clinic have in place are having success. They improved in overall satisfaction from the 55th percentile in 2008 to the 92nd percentile in 2012. Components of this include an increase in room cleanliness from the 4th percentile in 2008 to the 71st percentile in 2012, as well as drastic improvements in nurses’ communication, doctors’ communication, communication about medication, pain management, staff responsiveness and discharge information; all respectively from 2008 to 2012.

3. I have a dose of skepticism (healthy, I hope) regarding the transformation to “patient first”. As the health care industry has a strong component of capitalism at its core with a willingness to participate in already questionable lobbying engagements, the entities that are changing to this motto would just be following along the lines of the “customer first” in any normal service industry. I suppose though any consideration of the patient (or customer) is better than none. Initially, I was put off in knowing that Cleveland Clinic doctors were still making equivalent compensations to that of their equals in other clinics, hospitals, etc. If their overall plan was to keep costs as low as possible for the customer, why are compensating at such an amount.  Unfortunately, the inefficiencies in the healthcare market have led to exorbitant costs in medicine, procedure, equipment, etc. which probably forces Cleveland Clinic into having to pay such salaries.  If they don’t, they wouldn’t be able to attract the doctors to provide the necessary care to their patients. Hearing that they charge at Medicare rates provided some balance. If more clinics adopted such a non-profit approach as the Cleveland Clinic, that might represent progress for me. 

However, as long as for-profit systems exist in health care, it will continual to be an uphill climb against patients receiving the short end of the stick in terms of costs, no matter how its dressed up. Cutting into such inefficiencies and costs, it does give hope to hear of technologies such as Blockchain that could revolutionize how EHR’s are kept, among other processes in the healthcare industry. Additionally, hearing of how discussion boards allowing common patients to communicate, (e.g., e-patient Dave) also give hope. Like any change, or revolution, it has to come from the people. Hearing the voices we’ve heard thus far into the semester provides hope that systemic issues in healthcare can be ransacked, reversed, reinvented, reformed, and given an appropriate Rx.

Clevland Clinic and Patient First

1) The Cleveland Clinic's overall strategy was to redefine how they treated patients in their care. With the message of "The patients are why we are here", the Cleveland Clinic did just that. Headed by Dr. Cosgrove, the clinic "tore down the hospital's organization and started over". The multidisciplinary teams were organized them to be more around the patient perspective and defined around disease systems or organ systems. Even offices were moved around and new institutes were set up to be led by a respected physician who was committed to a team culture with excellent managerial and interpersonal skills. "Support Institutes" were made and included patient care experience, legal, finance, marketing and human resources. By 2014, the Cleveland Clinic's patient satisfaction had improved and patients complaints dropped measurably. The Cleveland Clinic measured their success by focusing on the ability to learn and quality improvement by the teams. Transparency allowed the clinic to learn form their mistakes and grow from them.

2) One example of the Cleveland Clinic doing something well, was their cost reduction. The Cleveland Clinic focused more on having their physicians knowledge about the process of care and not just an analysis of charges. With transparency, the clinic was able to compare different cost approaches. With this new strategy, cost reductions resulted to $481 million, with $152 million indirect costs and $329 million in clinical costs. Another example of the Cleveland Clinic doing something well was their use of MyChart. MyChart included digital data and images, test values, doctors' reports, and extracted values from non-digital data. MyChart allowed both physicians and patients to view the same information. Patients were enabled to have control over all of their data, created and cancle appointments, request prescription renewals and contact their doctors.

3) In my experience, there has been a mix of both patient first care and just another sick person that a doctor had to deal with. The Children Hospital in Orange County, CHOC, was a place where I felt that their only interest was to treat the children with the best care possible. Although I was a young during my time there, and not looking at things like patient records, or costs, I felt that they truly looked after my wellbeing both physically and mentally. I would be regular checked on by my physicians and nurses periodically talked and did activities with me. On the other had, I have been in doctor care where it felt very impersonal, where money was the second most talked about topic and then followed up with where will the next time I see you. Which translated to me as when will you pay me next. So in my opinion, once patients experience a patients first type care, they will started demand or go to places where this is the number one strategy.

Cleveland Clinic

After reading the cases in regards to Cleveland Clinic, I did some follow up research to see what the Cleveland Clinic would be doing in the future as of recently with all of the innovation within technology.

The article talked a lot about the focus of "Patients First" and how that the hospital was doing alot of changes and improvements based on the Patients. The article doesn't necessarily talk about the patients from outside the hospital perspective but Cleveland Clinic has been working to improve that experience aspect as well.

http://www.crainscleveland.com/article/20171008/news/138041/cleveland-clinic-more-accessible-insurance-products

Explains how the Cleveland Clinic has recently teamed up with major Insurance product companies such as Humana and Blue Cross Shield to improve the experience of "Patient First" outside of the hospital as well. Working with these insurance product companies allows the hospital to provide improvements with health plans that are more affordable for the public. Overall, this is a win-win situation for the hospital, gaining more patients, and providing major insurance companies with the opportunity to work with major corporations such as the Cleveland Clinic

Cleveland Clinic and Patients First Case

I think the biggest thing Cleveland Clinic has done to improve the value for their patients is patient education. The case spoke about the importance of patient satisfaction and the importance of ongoing engagement with patients. This means that it is crucial for the patients to know what is going on with their health, as well as what the next steps with treatment will be. Cleveland Clinic’s system gives their patients educational materials including post-evaluation information after visits for treatment of chronic to severe conditions. This information can easily be accessed online for free. 

This leads to the next way the clinic is improving the value for their patients, that is open medical records. Although the Cleveland Clinic has medical records open for their patients for several years, recently, the clinic has been creating new ways to access personal health records online. Within the past few years, 3.5 million lab results as well as images have been made available for patients to view online. Also, patients are now able to access the notes from a visit that were written by their physician. Another way Cleveland Clinic has driven value for their patients is the series of pilots projects they launched. These projects allow patients to input their personal data on their own which enables a flow of information between doctors so they can track a patient’s progress. Overall, the Cleveland clinic has improved the value for their patients by providing follow-up advice, clear communication channels that are easily accessible, and created new ways for physicians to track their patients progress.

One thing that stood out to me that Cleveland Clinic is doing well is the open access scheduling. Open access scheduling was a significant change in the clinic since it streamlined the way patients scheduled appointments. All of Cleveland Clinic’s health centers have the ability for patients to access the patient portal so they can see their provider’s availability, and patients can also schedule their own appointments. This is important for both the clinic and patient’s because it reduces the time needed to schedule the appointment.

I think that there is a “patient first” transformation in place for several different reasons. First off, this case spoke about several ways the clinic is putting people first. For example, the open access scheduling, doctor follow-up / progress tracking, and accessible visitation notes are all ways of putting the patient first. Aside from this case, one thing that stood out to me from this class about putting patient’s first was from the Escape Fire movie. In one section of the movie, a primary care doctor was emphasizing the importance of teaching preventive ways to prevent diseases. I think there is currently a movement for putting “patients first”, but I think it is too small for what it should be.

Cleveland Clinic and Patients First! Come Discuss With Me!

Since as of this post, there's no one else I can reply to, I think I'll try to stir up some discussions under here!

One of the big things that struck out to me in the article was the use of Information Technology in the clinics. The use of a software called MyChart allowed patients who signed up to immediate manage all of their information and to edit it as they saw fit, allowing physician's a chance to go over it before they saw the patient. This, coupled with MyPractice, created an easy way of sharing information between the Clinic and it's patients.

In terms of IT, what other softwares or kiosks could a clinic potentially use to improve the patient care experience? Eliminating paper work and making everything digital is a good start as long as the data can't be compromised, but where do you go from there to continue innovating?

Although most clinics already use an electrical system for appointments, many places could use an upgrade in this department. Checking in patients, gathering information for average times per patient depending on factors such as age, disease, and doctor, could help create a more efficient patient flow, leading to severely reduced wait times (Ever had an appointment for 1pm that didn't even start until 2:30pm? I see room for improvement there).

Health Care Fanatics and Patients First!

From the HBR article, "Health Care's Service Fanatics," and the HBS Case Study, "Cleveland Clinic: Growth Strategy 2014," the CEO at the Cleveland Clinic (also posted in D2L under Written Assignments), Dr. Delos "Toby" Cosgrove’s central message to employees had been Patients First!, which demanded relentless focus on measurable quality. Ensuring quality, in Dr. Cosgrove’s view, included improving structure, processes and outcomes. “This included constant attention to patient safety, respect for the patient’s dignity, excellence in housekeeping services and facilities, and genuine concern for the patient’s emotional wellbeing and care experience.”

Dr. James Merlino became Chief Experience Officer in 2009. Merlino defined the patient experience as "everyone and everything people encountered from the time they decided to go to the Clinic until they were discharged.” He worked to make patient experience insights more tangible by asking the question: “How can processes and metrics drive improvements in the patient experience.” He identified three critical areas: effective processes, caring caregivers, and engaged patients.

Consider these questions as you read and reflect on this case (and the other articles posted on this topic).  Remember to interact by replying to posts, rather than posting individually your responses.

1. What is the Cleveland Clinic’s overall strategy for improving value for patients? 
2. Are there examples of what Cleveland Clinic are doing well, or areas where they may still need improvement? 
3. What do you think of other efforts presented in the class schedule, or examples of your own, that make you feel like there is a “patient first” transformation in place or are you skeptical? Explain.

Draft Proposal - I'd Appreciate Feedback on Any Ideas!

For my area of focus this semester I am planning to further pursue the advancement and adoption of standardized Personal Health Records (PHR). While the idea of the PHR has been around for quite some time, and many hospitals and clinics across the nation now have them in some form, adoption among consumers has been mixed and likely far below where it should be. There are a number of individual portals for things such as finance, social media, academics, and shopping that have advanced and been adopted at a much greater pace than PHRs. Arguably, wide ranging and equitable access should be a hallmark of healthcare in the very near future.

There is a lot of research on this issue existing, and I have a couple of ideas regarding gathering primary data to investigate future adoption of PHRs. First, in order to gauge patient sentiment, I would like to conduct a primary survey of patients. By patients, I am planning on surveying a wide range of people, and not necessarily within the vicinity of a healthcare facility at the time of surveying, as most can be considered patients of the healthcare system at one point or another. I would like to include questions on this survey to gather interest in using a personal health record. Questions would gather data on if patients currently use a PHR through a care provider, if they would prefer a consolidated PHR or multiple portals, and how frequently they would access their PHR. I think one hard thing about this topic is I do not know exactly where I could find unique data sets to analyze, or how I could observe the process.

When it comes to a centralized portal for access to your PHR, there are a number of implications that should be noted. The first is that providing patient access to a wide-ranging personal health record provides one more area from which data can be compromised and exploited. Some patients may build accounts with weak levels of password protection for example, exposing their information to theft and compromise from malicious actors. Another concern is that if there was to be one centralized system online where PHRs were accessible, from hospitalizations to eye appointments, who would manage and develop the platform? Would it be a private entity that somehow was able to form partnerships and attain access to this data, or would the project be federally administered? Maybe a technology like block chain could be employed to ensure confidentiality of patient information. Additionally, some patients could possibly push back against having their information all located in one place, or in the possession of another group aside from their direct medical providers. Even if these issues were to be overcome, it is safe to assume that it would be a large capital expenditure to develop and coordinate such a strong system. There are a number of complications that could mean there are significant delays, or that it is never fully developed.

In the coming decade, or maybe just the coming years, I’d love to see a more comprehensive and accessible PHR portal be developed. Personally, I would use this information to check my immunization history, view transcripts from doctors’ appointments, and review my prescription history. Regardless of care provider or time, having all of this information quickly accessible in one place would be extraordinary for the average patient, let alone those who deal with chronic or terminal health conditions. Between now and then, I am hoping that through firsthand surveying I can gauge what patients are seeking and hoping for in this next wave of technology based healthcare advancement. If you have suggestions or ideas on what you’d like to see from my research, please let me know.

Triple Aim Video

As part of the systems project proposal (first draft), I wanted to introduce you (many times) to the Triple Aim Initiative, upon which the project is based. The video is now available publicly, rather than having to see it from the webpage.

Here is a link to the systems project on D2L (you have to sign on to D2L to see it).  In the meantime, watch the short video explaining the Triple Aim.


 


Once you watch the video, here is a pdf to the Concept Design for the Triple Aim.  It provides examples of the measurements and other details.  Only 3 pages.

Emory Case Study

The main reasons why Emory decided to implement CPOE systems were to reduce the number of medication errors, as before CPOE went live, physicians at Emory would place orders by writing them on an order sheet attached to the patient chart, and in some cases, they would call a nurse to write the orders on the order sheets. When this happens, it was not uncommon for the physicians to sign off orders that weren’t verified correctly by the nurses. There’s also the concern of lost paperwork, or illegible orders. Therefore CPOE systems are mainly designed to reduce, or eliminate handwritten orders.

These are all good reasons, but CPOE did not exactly eliminate all medical errors as some physicians, who are not as familiar with technology, would often put in the order for the wrong patient. However, it is definitely more efficient, as the doctors have the responsibility to enter in the order themselves, and they are entering it into the computer so it improved legibility.

Before adapting to CPOE systems, physicians would communicate verbally to the nurses to place the work order, but now with CPOE, every work order is now computerized. Physicians can enter in the information themselves digitally, and medication and other orders can be placed correctly.

Workaround, is when you use other methods than what the system is originally designed for, to get the work done. An example of this would be the physicians letting nurses place orders, without entirely verifying it, instead of writing it down themselves. I personally did not have much of an experience in working around the technologies that I use.

Some suggestions that I have for creating a culture where people are willing to adapt to unforeseen problems while using complex system like EHRs and CPOE, would be to just take it slowly step by step, and to train physicians to use technology. The systems should also be more user-friendly. Developers should work with physicians and nurses to develop one that would help them understand how to use the software better. I don’t exactly remember any major system changes while using computers, but while I was in my java programming class, I was first introduced Dr. Java, and then later introduced to Eclipse, which checks the java code more efficiently, but there’s more shortcut buttons that you need to familiarize yourself with to make use of the software.

Post URL and First Blog

Due by next class, 9/27.

Please comment below with the URL of your blog.  Post your first blog when you are ready to do so.  The first blog can be a summary of your research proposal.  Consider including a graphic, table, or image (see editing details above).  Remember to "Link" to any URL links on your blog post.

Emory Case Study

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 

Emory decided to implement CPOE because they are more reliable and easier to access than the previous system. After implementing CPOE, doctors can initiate orders online instead of signing papers. It reduces the probability of losing the paper. In addition, doctors can send the patients' exam online instead of through faxing.

They were good reasons because they free doctors and hospital workers papers, which are burdensome and hard to manage. CPOE allow both doctors and patients to view the details online.

• Why won’t CPOE’s eliminate all medical errors? 

CPOE cannot eliminate all medical errors due to man-made mistakes. According to a ground nurse's experience, CPOE is extremely difficult to use. Though CPOE has benefitted many emergency physicians in a significant way, it also brings trouble for those less technology savvy physicians. They would click on the wrong patient names.

The overall feedbacks from physicians are positive.

• What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

After CPOE, nurses no longer need to take notes from the doctor and let the doctor sign the order. Doctors will type in the orders himself. Doctors can also view the information through the sheets with a remote access. It improves efficiency and minimizes the mistakes.

• What is workaround, and how does a change in workflow make workarounds more noticeable? 

Workaround means that hospital workers work in a different way to achieve the goal instead of the normal way. They perceive that some problems are very hard to solve.

A disintermediation in Emory CPOE shifts the workload of nurses to physicians. Physicians complain about that because they have to do more. Nurses have problems reviewing the order because they no longer receive verbal orders from doctors. Pharmacists love this change because they are freed up from writing orders all day to walking around on the floor.

• Have you ever experienced anything like this in your work or school systems? 

U of A Campus Recreation Center has just renovated its locker room and introduces a new towel tracker. This move causes disintermediation between the towel renters and workers at rental area. Additionally, renters would no longer need to get into line and return the towels due to the micro trackers on the towel. While it saves trouble for most of us, people who are not so acceptable to the change needs to register their finger prints.






I suggest that people should be informed of the benefits change bring in a long run so that more people are welcoming the changes.

Emory CPOE Study

•What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 
 The reasons the Emory implemented CPOE was due to the number of unintentional medical errors that had been occurring, generally, in health care and as a delineation, the Emory hospital system.  Almost 900,000 injuries occurred, in 1984, due to errors in patient management in the U.S. - where more people died versus car accidents, breast cancer or AIDS.  Some examples of such type of errors occur through multiple transcriptions of an order or orders of medications.  Any attempt to mitigate the number of preventable errors, that does not worsen the problem, would seem reasonable to implement.  Though, as discovered in the article, there were consequences that resulted from implementing CPOE and hard evidence was not provided as to whether or not the incidents of errors decreased.

Why won’t CPOE’s eliminate all medical errors?
Initially, CPOE's will not eliminate all medical errors because of the learning curve involved in the adapting to the new system.  Changing such a process involves coming up against a great deal of rigidity by the involved agents, as described in the article, and they have to unlearn habits.  In the long-run, such incidents may decrease as knowledge and familiarity with the CPOE system increase by those in health care.  However, it is still dependent on human involvement which always opens the potential for error.

•What are the some differences between how Emory placed orders before CPOE and then after CPOE?
Before CPOE's more of the order handling was in the hands of the unit clerks and nurses who were entering everything by hand which could result in greater human error.  After CPOE was implemented, the doctors had greater responsibility in the placed orders and they were writing the orders through computers and not by hand.  There were some issues with the new system as not all the physicians were as proficient with correct entry and some confusion ensued on the proper form for entry.  There was also no gatekeepers keeping a "check" on the proper transmission of orders.  Some animosity resulted for both the physician increased workload and nurses who felt the system was too complex and cumbersome.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround was a way that an order would eventually make it to its desired result though not going through the normal process, but working around it.  These workarounds are generally inefficient and knowledge of how to do it was in a limited amount of persons' hands.  These workarounds were exposed when the CPOE system was in place as they could no longer "successfully" function like they could before CPOE.

Have you ever experienced anything like this in your work or school systems?
Yes, I experience such an occurrence of some new implementation every semester that involves an "de-training" of an old process and training of a new process.  The people who are no on board with the change do seem to create a bottleneck.  Many times such a new process is not effectively communicated to all the possible people involved and it is not unusual to find this and have to explain how a process has changed to another person.  There is definitely a domino effect that takes places and with pushback or poor communication the positive effects that could have resulted can be stunted.  Then an individual might feel entitled to say "see the process isn't working, lets go back to the old process".

Are there any suggestion you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE? Have you had to go through any major system changes in other parts of your life?
I think the best way to create a culture where everyone becomes more accepting to change is to be very clear of the consequences that the current system is having and then show clarity about how instituting specific changes will help to overcome such consequences.  And that every person's role in accepting this change is pivotal.  If there is any rigidity from people, then the consequences may end up worse than the consequences of the original system.  Also, sympathizing and empathizing that adapting to such changes are not going to be easy, that there may be headaches, but in the long-term it will be of greater benefit.

Emory Case: A Study By Ben Ampel

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

There were errors in the system due to manual order sheets. These paper sheets had to be verified, but sometimes were not before an order had already been carried out. Handwriting, lost paperwork, and a high number of changing hands for the paperwork created a high amount of errors.

CPOE allows medical institutions to move away from these handwritten papers, and removes the need for the nurse to potentially make mistakes when taking notes from the physician. Physicians now also have remote access to these sheets, allowing them information away from the hospital, which is reason itself for me to think that this was a good plan. The plan to improve patient care also seemed to be a success, although there was a mixed response from the physicians.

Why Won't CPOE's eliminate all medical errors? 

No system that has human input will ever eliminate errors. Many doctors are older and very hesitant to learn to operate the new system. They may accidentally select the wrong patient in the system, or enter information in an incorrect field. I'm an MIS major and I still make mistakes in the systems I use, of course doctors are going to make mistakes in their personal system.

But, overall, Dr. Matthews in the study states that errors were drastically reduced. So even though errors still exist, CPOE's have reduced overall error, and created a net benefit.

What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

It used to be that physicians would give a verbal order to their nurse. The nurse would then write the information down on an order sheet. The nurse would then verify the order by reading it back, and then the physician would sign off on it.

Now, the nurse has been taken out of the equation. The physician takes down all information on a computer, and saves the information right there. The sheets can be looked at through remote access, and medication can be ordered immediately from the system.

What is a workaround?  How does a change in workflow make workarounds more noticeable?  

A workaround is a way of completing a task in a way that the system was not intentionally designed for, or avoiding an problem part of the process. Workarounds can potentially be time saving. If workflow is changed, workarounds may become unusable as the system no longer allows the task to be completed without following all steps, which could exaserbate issues if the previous problem in the system was not fixed or updated.

Have you ever experienced anything like this in your work or school systems?

At the Rec Center, we've added new electronic waiver forms for patrons to sign when they purchase a membership. The way the system works is you're supposed to click through the entire assumption of risk form on a tiny touch pad and then sign, however the pad times out after 20 seconds. But if you click through one page and then tap where the "sign" button appears later, you can get into the signing part of the program, saving about 30 seconds of tapping through waiver, plus the potential problem of the pad timing out and needing to restart.

What about other workarounds you do for software you use now?

Other than what is done at the Rec Center, I try to use hot keys to automate processes in my software, but I'm not sure I use any actual workarounds in my day to day life to avoid issues or bugs in the software.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   

I believe training and information is the most important part of the process. If doctors know from the get-go that these systems will save them time and energy, they will be much more willing to deal with problems as they come. If physicians can't see the benefit of a system, then any unforeseen problem will just anger them further, leading to a much less productive day. Also keeping someone on staff who is always available to help with problems can help with productivity and positivity.

Have you had to go through any major system changes in other parts of your life using computers?

Again, the Rec Center likes updating their horrible system all the time, which only creates new and interesting problems to deal with. The people who actually use the system on a day to day are never consulted about changes that should be made, and this is obvious with every new update. Integral parts of the system break regularly, while areas of the system that are used maybe once a week for special cases work flawlessly.

Emory Case Study

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

Emory chose to implement a CPOE system to modernize their previous process that involved manually filling out order sheets. Some physicians would do this themselves, or even have a nurse do it for them. There were frequent errors occurring with orders, as things could be lost in the process, handwriting could be misinterpreted etc. I think the fact that too many errors were occurring is a good enough reason to choose to implement the CPOE. While it was an expensive change to make and a big one process wise, overall it led to a reduction in the number of errors occurring. 

Why won’t CPOE’s eliminate all medical errors?

Unfortunately, even in a computerized environment there is still the possibility for users and their input to create issues. An example of this is the physicians or whoever is doing the entries accidently placing an order for the incorrect patient. Additionally, ownership of placing orders was transitioned fully onto the physicians, when they did not complete them all previously, so that can cause errors as well.

What are the some differences between how Emory placed orders before CPOE and then after CPOE?

Now, all orders are placed by the physician directly, whereas it previously was often completed by nurses. They place all orders through the computerized system, and can place multiple orders for a patient simultaneously. The physicians can now also place the orders from anywhere they access the internet, not just in the hospital. This is all much different from previously writing orders or needing someone else from the hospital staff to do so.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround is a way that a process is circumvented, often without realizing you are explicitly doing so. For example, actions in a process that were considered unspoken rules, like not formally disclosing old orders, when that was supposedly part of the old process, issues can occur.

Have you ever experienced anything like this in your work or school systems?

Yes, I had experience creating a new electronic system to standardize a business process previously conducted over email. It quickly became clear that business users can be excited for a new system or way of doing things, but there can still be a lot of animosity towards change and doing things a better way unless they truly had a strong dislike for the old system.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?

My largest suggestion for those for those implementing large systems such as EHRs and CPOEs is to make stakeholder communication the foundation of the implementation. From gathering requirements through a go-live, the more opinions you can gather and education you can give, the better off you will be. Even though it can be a pain as the developer or implementer of the system, your subject matter experts will be more than happy to offer their insight and tips, and they’ll likely be very valuable and encourage adaptable culture.

Emory Case

Change of any sort can be difficult but more so for an industry that has been doing something the same way for about a century. Emory Healthcare was founded in 1905 and, although they made some small IT advances in the 90s, used the same way of order processing until around 2005. When President Obama and congress made it a focus to enhance health information technology by enacting a stimulus package that invested $19 billion in the area. This change was met with resistance but Computerized Provider Order Entry Systems (CPOEs) were made with the goal of reducing adverse drug events and making the process more efficient as a whole.

Emory Healthcare is the largest health care system in Georgia so the overhaul that they experienced was on a large scale. They have 4 hospitals with 1,184 licensed patient beds along with 9,000 employees. Whenever you implement a change that will affect people on this big of a scale there will definitely be some hurdles. In the past, physicians would write patient orders on order sheets or have nurses do it for them. Nurses were supposed to read back the order and physicians would sign off if it was correct but there were some instances where the physician would sign off on it after the order was filled. This could create some errors because of miscommunication and was not an efficient way of filling orders but was what they were used to for so long.

CPOEs changed this process and put the responsibility mostly on the physician. This may have caused some unwanted work for the physician but was a much needed advancement. The physician or another provider with the correct privileges would enter the orders on the hospital computers. The physician could put in orders from anywhere with internet access which made things more efficient. The implementation of this was met with mixed reactions. Some liked the customization but other less technologically savvy physicians saw it as a hindrance to their work.

The value of CPOEs is still debated but most healthcare employees would agree that it is a needed and important step for our healthcare system. Adapting to the digital world will be easier and easier as the years go on because almost everyone has some sort of understanding about technology. Studies have shown that they do reduce adverse drug events but they are not conclusive. They can also cause different kinds of errors not seen in written orders. The investment in health information technology should be continued as more advances arise making it easier for patients to get quality care.

Emory Case

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 
• Emory's Healthcare was one of the largest health care systems in Georgia. With over 1100 licensed patient beds, 9000 employees, and 1000 community physicians, keeping track of the patients record was a very complex system. Prior to CPOE going live, Emory placed all of their orders hand written through an order sheet. Communication wise, verbal orders we're allowed and all orders for medications were faxe or scanned then sent to the pharmacy.

• Why won’t CPOE’s eliminate all medical errors? 
• Although CPOE's dramatically improved their system and was overall very satisfying for physicians and employees at Emory. With that being said, not all of medical errors can be eliminated. Regardless if it is paper or electronic, there always is a possibility that one can enter in the order incorrectly. Whether it is for the wrong patient because the mouse was a little off and physically typing in the incorrect part, CPOE's are not capable of eliminating ALL of the medical errors because of the human mistakes.  

• Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   Have you had to go through any major system changes in other parts of your life.
• I believe a potential issue with things such as this are the users of the systems. Regardless of the industry, there is always a big range in terms of age of the users of the systems. A young physician who just got out of medical school is obviously going to be much more adaptable to a electronic system change such as CPOE compared to an older generation. It is necessarily the actual system that causes this chaos, but I believe it is more of the concept of change.  

Emory CPOE Case Study

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

Prior to the CPOE implementation at Emory, physicians were writing out order sheets by hand and submitting a verbal request with a nurse. Everything from placing stat orders to sending medication forms to the pharmacy all went by the unit clerk. After implementing the CPOE system, the entire ordering process changed by holding the physicians accountable. The CPOE system enabled physicians to: place orders with a computer (instead of writing it down), place orders as long as they were connected to the internet, and enabled physicians to place their own lab / radiology orders rather than having the unit clerk place them (3, 4). I believe the implementation of the CPOE system was positive overall. The positive effects include; the new order entry system is very customizable which allows the CPOE team to continuously improve the system, the system put more work on the physicians which let other healthcare workers perform other tasks, and the electronic ordering eliminates and reduces errors.

Why won’t CPOE’s eliminate all medical errors?

The CPOE will not eliminate all medical errors due to human error. As Dr. Matthews said, “The most common mistake that you see is orders entered on the wrong patient, because the mouse was off by a few millimeters when you selected an order” (4). On top of this, there are less computer-savvy physicians who reject using CPOE since it is a hindrance to medicine. While neglecting to use the CPOE system isn’t directly linked to causing errors, I believe that there will be more errors for the physicians who choose to write orders. Lastly, I think there will still be medical errors that arise with software and hardware problems. All software, including Emory’s new CPOE system, will need continuous improvements to keep the system up and running smoothly.  

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?

Personally, I have encountered a situation where people are opposed to adapting to a new system that they do not see the benefits too. This summer I interned at a commercial real estate company. The company was looking into using Salesforce in order to better manage there 20+ accounts. Each account contained several agents, neighborhoods, clients, financials, contracts, and so much more. In the first few meetings we spoke about using Salesforce, half of our team was split thinking that, “it wouldn’t be a good option”. However, after further instructional videos and demonstrations from salesforce, our team was able to grasp the benefits from the new system. I would recommend this similar process when implementing a new system like EHRs or CPOE. Make sure you let your team (or company) understand the benefits of the new system and how the new system improves upon the past systems faults.

Emory Case Study Questions

As you read the case, "Computerized Provider Order Entry at Emory Healthcare" consider the following questions: (You can write it as a paragraph and include any issues that stood out for you as you read the case.) These questions are mostly to serve as prompts for thinking. Feel free to reply to others' posts, and add your own view.

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 

• Why won’t CPOE’s eliminate all medical errors? 

• What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

• What is workaround, and how does a change in workflow make workarounds more noticeable? 

• Have you ever experienced anything like this in your work or school systems? 

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   Have you had to go through any major system changes in other parts of your life?

Eller Healthcare Career Panel, October 12

The Eller Healthcare Career Panel will be held October 12, 4-6pm, in Berger 201.

RSVP for Healthcare Panel on eSMS

Panelists include:

• Sam Burns, COO, Agape Hospice and Palliative Care
• Matthew Hawkins, President, Sunquest Information Systems
• Judy Rich, CEO, Tucson Medical Center
• Jenna Lefkowits, Sr. International Product Manager, Advanced Staining, Ventana Medical Systems
• John Flores, Speciality Regional Sales Manager, Astellas Pharma
• Joshua Compton, Associate, Mercer

Others are pending, so once I learn more, I will add it.

Colonoscopy anyone?

The article focuses on one patient’s (Ms. Yapalater) financial experience with her colonoscopy and zooms out to explain that such an experience is not an anomaly, but instead the norm with an average colonoscopy costing close to $3,000 on average. With more than 10 million people getting them every year, the final tab is a profitable one for healthcare. Mentioning the size of the health care industry, $2.7 trillion, and examples of other severe price-inflated medical procedures.

The most expensive screening test routinely undergone, colonoscopies are a perfect example of what is wrong with the healthcare system. The procedure done in the U.S. does not provide any additional benefit vs. same procedure done in another country, but with the amounts that are able to be charged for them, they are increasing in popularity with an industry which has “business plans seeking to maximize revenue”.

Colonoscopies are no longer done in a physician’s office but in a surgical center, which were designed to reduce costs. However, it has actually increased the costs as additional services, costs are tacked on. The healthcare industry has propagated colonoscopies vs. other less-expensive, less-invasive screening procedures even though research shows colonoscopies do not provide prevent colon cancer any better. With the demand for the procedure increasing over 50% between 2003 to 2009, prices have inexplicably gone up, not down. Part of the reason for this is the use of anesthesiologists had doubled for the procedures over this time period.

The most interesting part of the article mentions that the insurer negotiated down each final bill in the colonoscopy cost data that it surveyed. Just the idea that it is common for a hospital or doctor bill to allow for negotiation of their bills should cast some suspicion on its pricing policies. It is also mentioned that there is a different pricing structure for those who have Medicare, as Medicare has more leverage in negotiations and able to ask for a lower price. It is fascinating to know that price discrimination laws don’t apply to the health care industry.

Paying Till It Hurts: The Continuing Debate Over Health Costs

The Continuing Debate Over Health Costs

http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html

The start of the article talks about how there are new tools for that consumers "patients" can look up relevant medical costs near them. The company UnitedHealthcare has both online and mobile tools that people can use. An interesting statistic in the article was by Truven Health Analytics reported, "$36 BILLION could be saved each year if the median prices for the 300 most common procedures", at first I thought it was in the millions but when I reread it and saw the B, I was truly shocked and then the UnitedHealthcare website and mobile app seems to be even more useful.

The article then shares letters to the editors by healthcare companies, doctor agencies, and specialists talking about the "new" article "The $2.7 Trillion Medical Bill" and their opinions about it. The 3 authors of the letter to editors all had in their letters that they believe that the patients deserve the best care. The Sedative agency believed that they costs were deemed worthy due to the complications and difficulties. The doctor was the one that talked about the healthcare system being a mess and their needs to be more than one way to solve it.

NYT Paying Till It Hurts: Vaccines

In the article, "The Price of Prevention: Vaccine Costs Are Soaring" Elisabeth Rosenthal goes into detail about how vaccines' costs have been increasing to a point where doctors are debating whether to offer shots. Vaccines have been a surprisingly hotly debated topic but they are still one of the most important things that benefits our public health safety. This article dives into all of the different influences that go into pricing, demand, and availability of vaccinations and how they all tie in together. Rosenthal strategically highlights stakeholders from each party effected by this conundrum to demonstrate how this is happening and what the long term effects could be. She points out pharmaceutical manufacturer Pfizer and their popular vaccination Prevnar 13, pediatrician Dr. Lindsay Irvin, San Antonio mother Breanna Farris, and government agencies like the Center for Disease Control and Prevention and Advisory Committee on Immunization Practices. All of these stakeholders play a roll in how vaccines are priced and give you insight to another part of the healthcare system that is not working correctly.

When the polio vaccination was invented it was a joint investment of funds between the federal government and different foundations. Pharmaceutical manufacturing companies have changed the way vaccines are made, patented, and sold through the privatization. Rosenthal points out that since 1986 the cost to vaccinate a child up to age 18 under private insurance has rose from $100 to $2192. Now, it should be pointed out that these costs may be explainable because of the added regulations and hurdles these companies have to go through to get vaccinations produced. There were measures to change the number of subjects mandatory for a vaccine trial from thousands to tens or even hundreds of thousands subjects. Added to the fact that making vaccines is a risky market to get into, these factors may explain some o the rising costs but definitely not all of it. Manufacturers have historically experienced small losses on vaccines because of the public health benefits forcing the companies to make them easily available but now are turning profits. The article points out how the cost for Prevnar 13 has been rising about 6% ever year since 2002 although the vaccine has not changed much. These rising costs should definitely be looked into by the government to decide whether there needs to be a correction to the market.

Government agencies play a large roll in the way demand for vaccines has caused some of the price increases. Rosenthal outlines how most pharma companies look at the FDA approval to be the most important thing for their drugs success but it is different for vaccines. The Advisory Committee on Immunization Practices is the most important government entity for vaccines because they give out mandates or strong recommendations to parents to get a certain vaccine. If the committee decides a vaccination should be mandatory for schools then the parent has no choice but to get their child vaccinated. These decisions may have direct influence on the price of the vaccine as pointed out by this article. In Singapore, Prevnar 7 was being evaluated for school mandate use. Before the committee made it mandatory it was selling at about $80 per shot but after it shot up to $120. These mandates, although beneficial to public health, can cause unforeseen price increases as well.

Finally, it is all tied together through the pediatrician Dr. Lindsay Irvin and San Antonio mother Breanna Farris. Due to the increasing price, Dr. Irvin tells us that she loses money on every shot she gives. The article states that insurance companies are supposed to cover all out of pocket cost because of the Affordable Care Act but in reality they cover on average about 40-100% of the cost. They rarely cover all 100% when overhead is taken into account so family doctor offices must make the terrible choice whether or not to offer immunizations. All of these decisions and factors come down to the direct stakeholder, Breanna Farris a mother from San Antonio. When her and her two kids moved to Texas, they were told when they entered school that Farris's daughter needed extra vaccinations because of the school mandate. She called 10 different pediatricians to find someone that was offering immunizations and was covered by her insurance but no luck. Her daughter missed a week of school trying to find the vaccine. They ended up being forced to go to a public health facility and lie that they didn't have insurance so they could get the vaccine.

When it comes to children's lives and the public health safety for all, making profits should be the last goal of these pharmaceutical manufacturing companies. This article really opened my eyes to all of the various factors that go into the pricing of these crucial vaccines and how it is a similar problem for many parts of healthcare. Rosenthal does a great job pointing out all of the different roles and how they tie in and can cause some horrible consequences.

NYT Pay Till It Hurts Case Write up

Article Title: “The Odd Math of Medical Tests: One Scan, Two Prices, Both High”

In the 2014 article “The Odd Math of Medical Tests: One Scan, Two Prices, Both High”, the article starts off by talking about Len Charlap, a retired math professor, who has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital that lasted less than 30 minutes. The next, was at a premier academic medical center in Boston, that took three times as long and involved a cardiologist. However, the charges seems to be backwards. The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. The drastic price difference confused poor Mr. Charlap.

The article further analyzes the Medicare payments between the teaching hospitals in Boston and other hospitals within cities like Philadelphia. It is just as Dr. Naoki Ikegami, a health systems expert at Keio University School of Medicine in Tokyo, and affiliated with the University of Pennsylvania's business school said, "One of the things about U.S. health care system is that it defies the laws of economics, and of gravity. Once the price is high, it just stays there.”

Using Mr. Charlap’s case as an example, two major takeaways from the article are: 

1. The more machines, the higher the bills.

Testing has become "what liquor is to the hospitality industry: a profit center with large and often arbitrary markups" in the United States' medical system. Like the recent Iphone 8 and Iphone X phenomenon, where the systems are similar, the phone with newer bells and whistles is the one that’s being charged at a higher price. “Someone might feel, ‘I bought the expensive new machine and this patient is insured, so I might as well use it,’ ” said Dr. Barry S. Lindenberg, a cardiologist in Schenectady, N.Y. “We have to be honest, there are abuses.”

2. Stubborn model of payment.

The article also mentioned that despite Japan’s fondness for testing, its health spending is about $4,000 a year a person, or 9.6 percent of gross domestic product. By contrast, the United States spends more than $9,000 per person annually, more than 17 percent of G.D.P., although some studies indicate that health care spending is leveling off. The difference is in part because Japan decides the value of each test and medicine, sets a price and then demands that it decrease over time. However in United States, it’s a totally different case. New Jersey had the second-highest charges for echocardiograms in the nation in 2012, 8.4 times Medicare’s approved rate. Despite having machines that are newer, more cost-efficient, and provide clear snapshots of the heart, it is not used as often in the United States as in other countries. For example, the newest miniature echocardiogram machines can fit into a doctor’s white-coat pocket and, placed on the chest during an office exam, provides a snapshot of the heart. Even primary care doctors in training can use the devices, which sell for well under $10,000, to detect basic heart problems with a few hours of instruction, according to studies. Because there's no profit involved, the doctors in the United States do not use it as it does not fit the United States' model of payment. It is still an ongoing issue that needs to be changed.

NYT Paying TIll It Hurts Ben Ampel

Article Title: In Need of a New Hip, but Priced Out of the U.S.

Michael Shopenn needed a hip replacement. His options were pay $65,000 out of pocket for all expenses at a U.S. hospital, or $13,660 in Brussels. His insurance wouldn't cover the cost, due to a pre-existing sports injury. Even though prosthetics for his condition only cost $350, the markup is incredible for everything else. The fact is, nothing stops companies and hospitals from these insane markups, and people will pay the cost due to necessity. 

With the rise of people needing or wanting joint replacements, these companies are only going to be able to gouge prices more and more, especially since none of them are willing to undercut the other. 

This article really opened my eyes to how bad things have gotten in the United States. You always hear how bad things are, but being able to put actual numbers to the inflated prices (10,000% markups) really opens your eyes. And these companies don't feel any remorse. An executive for one of these companies argued that "the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference" (Rosenthal). Except the tax was only 2%, and government interference is already minimal. The cost in Brussels is significantly less, and they use government regulation for healthcare. 

This article was published in 2013, and as recently as 2015, these prices have not changed for the better (Japsen). I think without regulations, these prices will only continue to get worse, as these companies are aiming for double digit growth every year, which isn't sustainable with lower prices. Worse, the companies still aren't putting their gross profits into R&D, which only accounts for 5% of their overall spending. These replacements aren't improving, and haven't had any breakthroughs in decades, yet keep getting more expensive (female specific replacements were actually more expensive, even though they use less material).

With an aging population, we are going to start seeing a mass exodus in either personal bankruptcies due to necessary joint surgeries, or vacations to other countries for more affordable care.  

NYT Pay Till It Hurts Case Write up

Article Tittle: American Way of Birth, Costliest in the World

The most wonderful event can happen in a hospital is giving life to newborn baby, you or the couple has finally become a father or mother. Hurray and congratulation! However, this excitement is not something you will see in this article, rather is the reversed of that slice of happiness. Ms. Martin before her pregnancy delivery, she started inquiring the expected pregnancy cost at her local hospital. The financial office was not very clear on how much it would charge her, but only gave her an estimate cost from 4,000 to 45,000$. Ms. Martin was upset on how they wouldn’t know her delivery cost, they are the hospital, and they should know. Meanwhile when she was trying to figure it out her estimated delivery cost, she received a couple bills for other visits. The bill consists of ultrasound scan and was asking for a discount when she already paid for a radiologist to read her test. Uninformed on how the bill is generated, she was charged for 935$ for the ultra sound test regardless if the machine was there for many years. Ms. Martin was outrageous and cheated by the system, she was confused on how “we” live in a first world country still receive an expensive bill for only giving birth to a new life? This bill (maternity cost) compare to other first world countries like Germany, United Kingdom, Switzerland, and France are not that expensive, even in third world countries, they received a better care and lower price for a healthy delivery. But the question for her is why in the U.S? It’s like everything has been label, everything has a specialist and are charging for absurd things that they shouldn’t.

From my own perspective view, I also feel that it’s very absurd and very disturbing on how the health care system and hospital bill works in the U.S. It’s like there is no one in charge of it to begin with, the price and bill are created based on what they wanted. This is insane and ridiculous with the system and set up, it’s like every specific thing is being charged in the hospital like what we have been discussing during the class. In my opinion, I think pregnancy to begin with they should not charge it excessively or none at all, after all the mother is giving birth to a new life and that new life is what keeps humanity alive. Human should be prioritized more important than money, however, for hospital, they value capital over humans’ lives. Then, where do humans belong to?

Rising Diabetes Costs

Even Small Medical Advances Can Mean Big Jumps in Bills (Link)

In this segment of Pay Till It Hurts, the major issues surrounding ballooning costs regarding Type I and Type II Diabetes is discussed. I’ll preface this by saying that the diabetes market is severely broken and in disarray, and at best the most encouraging thing that remains is that Type I diabetics still have opportunities to receive insulin and live encouraging lives in contrast to the former status of Type I diagnosis as a terminal illness.

There are a number of concerns and strain points to illustrate about the state of the industry, and I will dive into a couple key takeaways also. The first main point outlined in the article is the consistent iteration of diabetes equipment and infusions that has led to soaring prices over the years with marginal increase in improved patient outcome. Since the development of insulin therapy in the 1920’s or synthetic insulin in the 1970’s, diabetics began having options to control their health issues with a minimum viable product of sorts. None of the technology was revolutionary by modern day standards, but the medical concepts were fully established and scalable to save and improve millions of lives. While there have certainly been large improvements, the past decade has led to more aesthetic and non-critical improvements that have pushed device and infusion maintenance costs soaring market-wide.

Patients worldwide also face is the increased rate of obsolescence in pumps and meters as well as monitoring and maintenance strategies. The more tech integrated into diabetes management, the more diabetes management companies behave like tech companies. There are ever increasing interoperability issues and software issues as the latest and greatest is rolled out, and legacy treatment methods and platforms begin to lose service support and become ever harder to purchase. The captive market of Type I diabetics specifically is becoming more and more susceptible to being treated as hostages at the will of prices the market will bear.

Given these two issues, I’ve identified key takeaways and opportunities for the dire tide to shift that is looming over the diabetes sector of healthcare.

1.     Bargaining Power Needs to be Unleashed

In the discussion of why costs are so high, I found this factoid to be especially shocking: “Medicare is not allowed to bargain for insulin prices.” I found it shocking that a federal program with such clout was unwilling to drive down costs for patients. It is important to note however that most Medicare patients pay insulin costs out of pocket, and it is not covered. Even so, given the fact that there are likely a quarter million Type I diabetics under Medicare (based on rough calculation), any ability to make industry behemoths uncomfortable about pricing could reap massive benefits to consumers. Especially when there are only three nationwide producers of synthetic insulin, and one manufacturer, Medtronic, gripping over 60% of insulin pump market share.

2.      Dire Need for Competitive Disruption

Off that pervious point, the competition for key components and drugs within diabetes care is quite scarce. There are often very few large players that run the table, and solid, strategic, and fast-moving market disruption centered on affordability and reliability may be the only true way for competition to drive prices down. Please see this supplementary blog post by a diabetes industry advocate of what would truly need to happen to disrupt the market and reverse market trends, it’s a great read.

All things said, the challenges facing improvements in this healthcare space run the gamut, from unchecked market factors to questionably beneficial product improvements increasing cost. Serious change will need to be made through the concentrated advocacy of diabetics nationwide, government and private industry players, and maybe a little well-timed luck.