Liberals are outraged and conservatives are overjoyed. While the Population Health Blog is neither, it was interested enough to go to the Supreme Court's opinion page, read the majority opinion and and pull some of the more telling quotes:
Just where did the contraception mandate come from?
"....the Affordable Care Act requires ... health-insurance coverage to furnish “preventive care and screenings” for women without “any cost sharing requirements.” Congress itself, however, did not specify what types of preventive care must be covered. Instead, Congress authorized the Health Resources and Services Administration (HRSA), a component of HHS, to make that important and sensitive decision. The HRSA in turn consulted the Institute of Medicine, a nonprofit group of volunteer advisers, in determining which preventive services to require.
The [IOM] Guidelines provide that nonexempt employers are generally required to provide “coverage, without cost sharing” for “[a]ll Food and Drug Administration [(FDA)] approved contraceptive methods, sterilization procedures, and patient education and counseling.”
Rights of corporations vs. the rights of individuals.
"A corporation is simply a form of organization used by human beings to achieve desired ends. An established body of law specifies the rights and obligations of the people (including shareholders, officers, and employees) who are associated with a corporation in one way or another. When rights, whether constitutional or statutory, are extended to corporations, the purpose is to protect the rights of these people. For example, extending Fourth Amendment protection to corporations protects the privacy interests of employees and others associated with the company. Protecting corporations from government seizure of their property without just compensation protects all those who have a stake in the corporations’ financial well-being. And protecting the free-exercise rights of corporations like Hobby Lobby, Conestoga, and Mardel protects the religious liberty."
Religious liberty?
"...we must next ask whether the HHS contraceptive mandate “substantially burden[s]” the exercise of religion. We have little trouble concluding that it does. [The objecting parties] have a sincere religious belief that life begins at conception. They therefore object on religious grounds to providing health insurance that covers methods of birth control that, as HHS acknowledges may result in the destruction of an embryo. By requiring ... their companies to arrange for such coverage, the HHS mandate demands that they engage in conduct that seriously violates their religious beliefs."
Does this mean coverage of vaccines and blood transfusions are at risk of being litigated?
"HHS and the principal dissent argue that a ruling in favor of the objecting parties in these cases will lead to a flood of religious objections regarding a wide variety of medical procedures and drugs, such as vaccinations and blood transfusions, but HHS has made no effort to substantiate this prediction. HHS points to no evidence that insurance plans in existence prior to the enactment of ACA excluded coverage for such items. Nor has HHS provided evidence that any significant number of employers sought exemption, on religious grounds, from any of ACA’s coverage requirements other than the contraceptive mandate"
What is the way out?
"The most straightforward way ... would be for the Government to assume the cost of providing the ... contraceptives at issue to any women who are unable to obtain them under their health-insurance policies due to their employers’ religious objections. This would certainly be less restrictive of the plaintiffs’ religious liberty, and HHS has not shown that this is not a viable alternative."
Image from Wikipedia
Monday, 30 June 2014
Saturday, 28 June 2014
Bikini Contest Preparation // One Week Out!
Hi friends! If you're reading this, you may have stuck with me from the very beginning when I started training for this NPC Bikini Competition. Thank you so much! I have felt the support and it has encouraged me all the way to this point- with just one week to go. I've mentioned before on my Facebook page and Instagram that I often read my Instagram comments and respond while I'm doing cardio. I can't tell you how much it helps to feel like people are rooting for you. The day of the contest, the women may look all glammed up, but most of the time, we are stinky, sweaty messes, always in workout clothes without hair and makeup done. I have to say that one of my most favorite times of the day is AFTER working out when I get to take a long, hot shower and get all fresh and clean. When you aren't getting lost in the comfort/joy of food and eating, you are forced to find pleasure in other things. I'm still enjoying my coffee (so much) and have a new appreciation for showers! :)
I started deliberately trying to get in shape in February 2014 and started working with my trainer (John Sherman) at the end of March 2014. We will have trained together for 15 weeks next week to get ready for this competition. You get to know someone when you're spending that much time with them and I've become really fond of him and can say we're friends now. I also respect his experience and training style. He is an IFBB professional bodybuilder (competing for over 25 years) and has made quite a name for himself in the fitness arena, but you'd never know it by meeting him. He's so humble and never one to draw attention to himself. I've never even seen him in shorts (he always wears pants). I think he doesn't want to "show off" or have people make a big deal about the size of his legs. He trains people locally in Houston, but also offers online training and meal plans. You can connect with him via email: johnjsherman@sbcglobal.net (I asked and he said I could give you his email address). My previous trainer from a few years ago recommended him to me. He trained her for the fitness competition that she won.
The gym we train at is small and full of people of all ages, shapes, sizes, and ethnicities. It's mostly people working out with trainers and since I've been going almost every weekday, I've come to know most of the people there. The sense of community and comradery is great. We "eye" each other knowingly with exhaustion while under the supervision of our trainers. Some of them are training for competitions also, so we'll keep up with whose contest is coming up next and hand out well-deserved compliments. My friend (who just turned 50!) is training with another trainer there for her first bikini competition in late July. I was intimidated by this gym when I first started going (it felt so "hard core"), but over time, I've become comfortable there and it almost feels like my home away from home.
By now, my diet and exercise are the norm for me, so it's really not all that hard to stick to my diet. I've found food that I like to eat and that makes my days much better. Of course, I have typical cravings like anyone else, but I know that in just a week, I can (guilt-free) eat whatever I want. High on the list of "whatever I want" is Mexican food, pizza, ice cream, brownies, cookies - all the dessert stuff. My husband has joined me in my meal plan this last month (God bless him!) and that's makes it so much easier because I don't have to make something different for him. He's lost 11 pounds!
Lots of logistical things are falling into place. I have my bikini and I love it! I had it made at Stakked Couture and it came out beautifully. It's turquoise with aquamarine crystals and rhinestone connectors. They were great to work with and helped talk me off the ledge when I first tried it on and was saying, "It doesn't fit, it's too small!!!!" They tried to console me, "Everyone says that at first until they get used to it." But, really, those bottoms, yikes!!!
- I also bought two rhinestone bracelets and a pair of dangly earrings, as well as my clear heels.
- I booked my spray tan (2 applications) with ProTan, the official tanning company for the contest.
- I booked my hair and makeup too. That's a relief! I'm going with the artists assigned to the show. I was relieved to hear they are only taking a limited number of appointments (10-12 women) because I didn't want to be rushed through.
- Hotel is reserved.
I still need to:
- Figure out what meals I need to pack, grocery shop, make sure I have a cooler to bring food in.
- Pack clothing, hair tools and makeup (just in case).
This week, I'll just be working out Monday, Tuesday, and Wednesday and "resting" Thursday and Friday. So far, my diet hasn't changed. I think it changes on Wednesday, so I'll let you know.
The show is on Saturday (July 5, 2014). Pre-judging (where they score the contestants) happens in the morning and then you get a break and come back for the night show around 5pm, I think. I still need the exact schedule. The night show can last until 10, 11 pm though. I was really hoping to go to a Mexican restaurant after the contest, but I'm afraid they'll all be closed by the time we finish!
I'll be posting pics to Instagram if you want to follow along next weekend. I'd love to hear from you! I'm sure I'll be a ball of nerves.
Oh, P.S. I took your advice and made an appointment to get my body fat measured at the Bod Pod because I'm really curious to see what it is. I'm not sure how accurate the calipers we've been using are. My appointment is this week, so I'll report back soon on the experience. :)
Wednesday, 25 June 2014
A Path Toward Further Health Reform Is Lined With the IRS?
As attention has shifted to phantom IRS emails, misbehaving Iraqis and our newfound national awareness of soccer's off-side rule, it's only natural for the Population Health Blog to wonder about the status of health reform.
Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.
Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2014 elections, Mr. Obama's veto power virtually guarantees the law's survival. The only question is whether politics will get in the way of any adjustments. Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).
Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back. He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.
Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes. Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact. Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.
The PHB is less sanguine. While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2013 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock.
The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.
Stay tuned!
Image from Wikipedia
Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.
Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2014 elections, Mr. Obama's veto power virtually guarantees the law's survival. The only question is whether politics will get in the way of any adjustments. Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).
Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back. He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.
Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes. Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact. Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.
The PHB is less sanguine. While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2013 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock.
The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.
Stay tuned!
Image from Wikipedia
Fat and Carbohydrate: Clarifications and Details
The last two posts on fat and carbohydrate were written to answer a few important, but relatively narrow, questions that I feel are particularly pertinent at the moment:
Read more »
- Was the US obesity epidemic caused by an increase in calorie intake?
- Could it have been caused by an increase in carbohydrate intake, independent of the increase in calorie intake?
- Does an unrestricted high-carbohydrate diet lead to a higher calorie intake and body fatness than an unrestricted high-fat diet, or vice versa?
- Could the US government's advice to eat a low-fat diet have caused the obesity epidemic by causing a dietary shift toward carbohydrate?
However, those posts left a few loose ends that I'd like to tie up in this post. Here, I'll lay out my opinions on the relationship between macronutrient intake and obesity in more detail. I'll give my opinions on the following questions:
- What dietary macronutrient composition is the least likely to cause obesity over a lifetime?
- What dietary macronutrient composition is best for a person who is already overweight or obese?
- Is fat inherently fattening and/or unhealthy?
From the beginning
Tuesday, 24 June 2014
A "Penny Dreadful" Take on Health Reform
To the spouse's enduring disappointment, the Population Health Blog has been ensnared by the Showtime horror series Penny Dreadful. Set in the 1890'sVictorian England, viewers can follow the derring-do of Dr. Frankenstein, Sir Malcolm Murray and Vanessa Ives as they quote Shelley and hunt for vampires.
The good news that even this corner of vacuous TV media, the PHB can find some lessons in health reform.
For example.....
Young Dr. Frankenstein creates a monster. While that's what you get for stitching miscellaneous body parts together and zapping the corpse with life-giving electricity, Dr. Frankenstein should also know......
1) things would have been worse if he had installed electronic health record in his laboratory, and
2) that's what happens when docs are too morose and wear far too much mascara.
When a ship hailing from Egypt has been quarantined by the London authorities because of supposed plague, the intrepid Sir Malcolm shrewdly deduces it is ultimate source of all the recent "chicanery." Since the ship is infested with lusty, blond and bloodthirsty vampire-vixens, his conclusion is correct. But, he should also be aware that....
1) the Veterans Administration has conducted an internal investigation and has found that no evidence that any patient has been harmed and,
2) he has given the PHB a reminder to use the word "chicanery" in a future blog post.
Dorian Gray is able to continue his dissolute libidinous lifestyle by standing in front of a painting and instantaneously curing his claw marks and, while he's at it, his probable sexually transmitted diseases. The PHB wonders if this is the key to harnessing the life-prolonging potential of telomerases, but it also cautions....
1) that this should be ignored by the medical community until it has been subjected to repeated randomized clinical trials and approved by the FDA, and
2) the U.S. government's deficit won't be helped by subjecting the painting to a medical device tax.
Dr. Van Helsing quotes from a lurid penny novel to prove that vampires do exist. This is an inspirational example of how early hematologists used disparate clues to arrive at obscure diagnoses. It is also....
1) a telling example of how doctors can quote from faux authoritative texts to support any predetermined medical conclusion.
After a long stay in a mental asylum for a "psychosexual disorder," Vanessa Ives is still prone to fits where her eyes turn white, she channels demons and she floats around the room. This is evidence that she needs to return to the asylum stat, but is also
1) obviously why thorazine-loaded blow darts were invented
2) better than the any of her battle scenes from the movie 300 Rise of an Empire
The good news that even this corner of vacuous TV media, the PHB can find some lessons in health reform.
For example.....
Young Dr. Frankenstein creates a monster. While that's what you get for stitching miscellaneous body parts together and zapping the corpse with life-giving electricity, Dr. Frankenstein should also know......
1) things would have been worse if he had installed electronic health record in his laboratory, and
2) that's what happens when docs are too morose and wear far too much mascara.
When a ship hailing from Egypt has been quarantined by the London authorities because of supposed plague, the intrepid Sir Malcolm shrewdly deduces it is ultimate source of all the recent "chicanery." Since the ship is infested with lusty, blond and bloodthirsty vampire-vixens, his conclusion is correct. But, he should also be aware that....
1) the Veterans Administration has conducted an internal investigation and has found that no evidence that any patient has been harmed and,
2) he has given the PHB a reminder to use the word "chicanery" in a future blog post.
Dorian Gray is able to continue his dissolute libidinous lifestyle by standing in front of a painting and instantaneously curing his claw marks and, while he's at it, his probable sexually transmitted diseases. The PHB wonders if this is the key to harnessing the life-prolonging potential of telomerases, but it also cautions....
1) that this should be ignored by the medical community until it has been subjected to repeated randomized clinical trials and approved by the FDA, and
2) the U.S. government's deficit won't be helped by subjecting the painting to a medical device tax.
Dr. Van Helsing quotes from a lurid penny novel to prove that vampires do exist. This is an inspirational example of how early hematologists used disparate clues to arrive at obscure diagnoses. It is also....
1) a telling example of how doctors can quote from faux authoritative texts to support any predetermined medical conclusion.
After a long stay in a mental asylum for a "psychosexual disorder," Vanessa Ives is still prone to fits where her eyes turn white, she channels demons and she floats around the room. This is evidence that she needs to return to the asylum stat, but is also
1) obviously why thorazine-loaded blow darts were invented
2) better than the any of her battle scenes from the movie 300 Rise of an Empire
The Majority of Medicare Spending Variation Is Unexplained
From time to time, the Population Health Blog spouse finds that her husband is insufficiently attentive. During a recent conversation about that very topic, things stopped when the PHB pointed out the window and exclaimed "Look! A squirrel!"
Naturally, the spouse is curious about the PHB's erratic attentiveness. Is it how its brain is hardwired? Too much sugar? Substandard parenting? And of all those possibilities, how much do each contribute?
That introduction should help the PHB and its readers check out this just-published Health Affairs paper on Medicare's erratic spending habits.
As PHB readers know, Medicare's patient costs patient vary from one locale to another by thousands of dollars, with no discernible impact on survivorship or quality. One narrative is that the health system is being consciously or unconsciously manipulated by doctors and hospitals at a regional level. Another is that poverty is causing patients in some areas of the country to have have more than their fair share of health problems.
Enter Laurence Baker et al, who wanted to know if patients' preferences are playing a role.
The answer is that it does. But, compared to hospitals and patient income, not that much.
The authors obtained Medicare claims data from 2005 and sorted it by Medicare Hospital Referral Region (or "HRRs," which can span several counties). They wanted to know if HRR costs correlated with 1) county and zip code-level median income, 2) self-reported health status, 3) the availability of doctors and hospital beds and 4) a six question survey that ascertained respondents' preferences for care based on scenarios like chest pain or cough.
The results?
The HRRs were grouped and sorted into low to high spending quintiles. As the quintiles increased, so did the number of hospital beds per thousand (2.2 low to 2.5 high), which suggested that the supply of services increases health care utilization. Doctors were negatively correlated (the more docs, the lower the spending, 214 per 100K low vs. 193 per 100K high).
Income was not correlated.
Patient preferences were correlated but only by a small amount (just over $100 across the quintiles).
It's one thing, however to have a correlation, it's another to know the strength of the correlation. Using regression analytics, the authors found that the availability of hospital beds and doctors could independently account for 23% of the low to high variation across the quintiles. Health status and income seemed to drive another 12%. Patient preferences explained another 5%.
While that explains approximately 40% of the low to high variation across the quintiles, that means 60% remains a mystery.
In other words, if hospital services, patient economic disparities and patient preferences were completely neutralized by very enlightened central planning, wholly just income redistribution and perfect patient education, only 40% of the cost variation across the United States would go away. Boston would still cost more than Boise.
The PHB's take:
1) Squirrels abound: there is still a lot that we don't understand about the national swings in Medicare's costs. Some areas are cheap, others aren't and the majority of that has little to do with the availability of hospital services, poverty or beneficiary preferences.
2) Any wonk, policymaker, politician, academic or blogger who offers "a solution" to Medicare's variation is kidding themselves. The majority remains outside the reach of laws, regulations or payment reforms.
3) Compared to Medicare, PHB's variable attention span is a comparatively modest problem. The spouse should take some comfort in that.
Image from Wikipedia
Naturally, the spouse is curious about the PHB's erratic attentiveness. Is it how its brain is hardwired? Too much sugar? Substandard parenting? And of all those possibilities, how much do each contribute?
That introduction should help the PHB and its readers check out this just-published Health Affairs paper on Medicare's erratic spending habits.
As PHB readers know, Medicare's patient costs patient vary from one locale to another by thousands of dollars, with no discernible impact on survivorship or quality. One narrative is that the health system is being consciously or unconsciously manipulated by doctors and hospitals at a regional level. Another is that poverty is causing patients in some areas of the country to have have more than their fair share of health problems.
Enter Laurence Baker et al, who wanted to know if patients' preferences are playing a role.
The answer is that it does. But, compared to hospitals and patient income, not that much.
The authors obtained Medicare claims data from 2005 and sorted it by Medicare Hospital Referral Region (or "HRRs," which can span several counties). They wanted to know if HRR costs correlated with 1) county and zip code-level median income, 2) self-reported health status, 3) the availability of doctors and hospital beds and 4) a six question survey that ascertained respondents' preferences for care based on scenarios like chest pain or cough.
The results?
The HRRs were grouped and sorted into low to high spending quintiles. As the quintiles increased, so did the number of hospital beds per thousand (2.2 low to 2.5 high), which suggested that the supply of services increases health care utilization. Doctors were negatively correlated (the more docs, the lower the spending, 214 per 100K low vs. 193 per 100K high).
Income was not correlated.
Patient preferences were correlated but only by a small amount (just over $100 across the quintiles).
It's one thing, however to have a correlation, it's another to know the strength of the correlation. Using regression analytics, the authors found that the availability of hospital beds and doctors could independently account for 23% of the low to high variation across the quintiles. Health status and income seemed to drive another 12%. Patient preferences explained another 5%.
While that explains approximately 40% of the low to high variation across the quintiles, that means 60% remains a mystery.
In other words, if hospital services, patient economic disparities and patient preferences were completely neutralized by very enlightened central planning, wholly just income redistribution and perfect patient education, only 40% of the cost variation across the United States would go away. Boston would still cost more than Boise.
The PHB's take:
1) Squirrels abound: there is still a lot that we don't understand about the national swings in Medicare's costs. Some areas are cheap, others aren't and the majority of that has little to do with the availability of hospital services, poverty or beneficiary preferences.
2) Any wonk, policymaker, politician, academic or blogger who offers "a solution" to Medicare's variation is kidding themselves. The majority remains outside the reach of laws, regulations or payment reforms.
3) Compared to Medicare, PHB's variable attention span is a comparatively modest problem. The spouse should take some comfort in that.
Image from Wikipedia
Sunday, 22 June 2014
Bikini Contest Prep // 2 Weeks Out
Hi friends! Now we are only two short weeks away from my first NPC contest. I'm excited and TIRED! Of course now that the contest is almost here there is lots of other home and family stuff going on, but I'm still managing to get my workouts in and stick to my diet. I just ordered Muscle Egg (chocolate caramel flavor) and cannot wait to get it. It's going to replace my shake as my last meal. I'm just not digging drinking a shake, but I think this will be more like chocolate/caramel milk. We'll see . . . I'll let you know how I like it.
Here's my latest progress picture taken on Sunday, June 22, 2014. I am really proud of what I've accomplished. I feel like a winner already.
TO DO LIST
There are lots of final contest details that I'm foggy on and trying to get completed, I still need to:
- Confirm hair stylist (or do it myself). I'm leaning toward doing it myself. I got my hair highlighted on Saturday, so I'm pretty blonde right now.
- Confirm makeup stylist. The show has one appointed to it and I emailed her to see if she has availability and to get pricing info.
- Confirm spray tan. I also need to decide if I'm doing it here before I leave or there. And if there, when? I'm going to call the contest spray tan company tomorrow to get more info.
- Go to my last bikini fitting. I need to make sure it fits and looks great.
- Buy jewelry. Earrings and bracelet only.
- Get nails done. I'm doing french mani/pedi.
- Make packing list. Clothes, food, cooler, camera, etc.
- Buy ticket to the show for my husband.
I'm sure there's more, but that's what I can think of off the top of my head. I have already:
- Registered for the show.
- Got my heels.
- Reserved hotel room.
My trainer has mentioned that I will only workout until the Wednesday before the show, then rest on Thursday, Friday and the show is Saturday. Backstage, before I go on, I'll lift light weights to give my muscles a little pump.
Also, on that Wednesday, Thursday and Friday, my diet will change and I'll cut out veggies and egg whites. I'm not too sure on the specifics of what I'll be eating besides chicken and potatoes or rice cakes, but I think the goal is to deplete sodium. I'll write a detailed post when I get more info.
THIS WEEK'S PLAN
My focus this week is to stick to my diet, no cheating!, and get in five 45-minute cardio sessions and 5 weight-training workouts with my trainer. I also need to try to get good sleep. If there's one thing I've learned during this prep it's that, if I don't get about 7-8 hours of sleep before my workout, it's excruciatingly difficult to get through. Oh, and I need to continue to practice my posing. I'll do 2 posing sessions with my posing coach this week. I woke up on Saturday morning and my back was so sore. It took me a little while to realize it was from my posing session on Friday. She was having me hold the line-up stage pose for several minutes (because I'll have to stand like that for possibly a long time on stage while all of us are up there) without fidgeting and while standing tall, sucking in, etc. It's not a very comfortable position to hold. I have a gift certificate for a massage- maybe I'll try to fit that in somewhere??
It's going to be a super busy week and I'm off to prepare my weekly schedule now- it's the only way I manage to fit everything in!
I hope you have a great week!
Wednesday, 18 June 2014
The Cost-Saving Elevator-Pitch for the Patient Centered Medical Home
Ready, set, elevator, go! |
Here's the PHB's elevator speech:
The PCMH comes down to two distinct - and separate - propositions:
1. "Reduce avoidable costs" by only applying the team-based care management and coordination to persons with all three of the following: a) chronic illness who b) are at high risk for future claims and c) are amenable to change.* All three must be present. This cohort typically represents a small, but "high return potential" fraction of a population.
The temptation is to blanket all patients with medical home resources, which increases program as well as claims costs and does little to bend the total cost curve. The "disease management" industry learned about "care creep" the hard way.
2. "Increase value" by enhancing quality and/or the experience of care with a modest - and relatively affordable - increases in costs. The relative increase in quality/experience is greater than the corresponding increase in program and claims costs, and represents a good deal for the health care dollar.
The temptation is to believe that quality/experience improvements lead to lower costs. Once again, the "disease management" industry learned about this the hard way.
* By the way, if the elevator ride is long, the PHB recommends pointing out that 1) predictive modeling/risk stratification can find the high risk persons and that 2) "change" includes modifying patient behaviors.
Image from Wikipedia
Tuesday, 17 June 2014
The Commonwealth Fund Keeps Score on U.S. Healthcare: Less Here Than Meets the Eye
YOU are in last place! |
Ugh.
Just when the U.S. prevailed against Ghana in the World Cup, we have to deal with being called a loser.
Naturally, the Population Health Blog decided to investigate. It discovered that the Commonwealth Fund ranked the U.S. against 10 other countries using a combination of multiple outcome measures.
Here's the complete report.
What does it actually say? Rather than attempt to summarize the report's findings, the PHB provides some telling quotes:
Quality:
"The United Kingdom ranks first and Norway last on quality, based on averages of the scores in these four areas. The U.S. falls in the midrange on this domain of performance."
Preventive Care:
"The U.S. does well in providing preventive care for its population. Respondents in the U.S. were more likely than those in most other countries to receive preventive care reminders and advice from their doctors on diet and exercise."
Effective Care:
"The U.S. is third on effective care overall, performing relatively well on prevention but average in comparison to other industrialized nations on quality of chronic care management."
Safety:
"These findings indicate that the United States has improved on safety indicators.... For example, the U.S. now leads all nations with a relatively low number of sicker patients reporting an infection during a hospital stay or shortly after."
Care Coordination:
"Eighty-three percent of American patients had arrangements for follow-up visits with a doctor or other health care professional made for them when leaving the hospital, second only to the United Kingdom."
Patient Centeredness:
"The U.S. ranks fourth. All countries could improve substantially in this area."
Engagement and patient preferences:
"The United States did well on most indicators."
So, since the United States is doing well on quality, preventive care, effective care, safety, care coordination, patient centeredness as well as engagement and patient preferences, what's the problem?
Again, some quotes:
Americans .... reported negative insurance surprises and the highest rates of serious problems paying medical bills.... On indicators of efficiency, the U.S. scores last overall with poor performance on the two measures of national health expenditures, as well as on measures of administrative hassles, timely access to records and test results, duplicative tests, and rehospitalization.
Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs.
The U.S. ranks last on mortality amenable to health care, last on infant mortality, and second-to-last on healthy life expectancy at age 60.
Plus this tidbit.....
Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.
The PHB's take? There is less to this than meets the eye:
1. The United States performs well on a majority of overall quality measures.
2. The United States suffers from high overall costs.
3. The Commonwealth Fund's ranking system faults the U.S. on two levels: value (our high quality comes at a very high price) and equity (persons with lower incomes cannot afford to access our high quality system). Add up the points in this scoring system, and the U.S. is last.
4. The Commonwealth Fund uses data from prior to the 2014 implementation of Obamacare, which was specifically designed to address the United States' shortfalls by subsidizing commercial insurance and increasing Medicaid enrollment.
5. By the way, despite little evidence in the report that cost, value or access are necessarily increased by the U. S. version of the medical home, the Commonwealth Fund included it anyway.
How well will all those high out-of-pocket "bronze plans," Medicaid, Accountable Care Organizations and the medical home truly reduce cost inflation, enhance value and increase access?
Stay tuned. The PHB is looking forward to seeing how they'll rank Obamacare's impact in 2015.
Best Sports Bras
This post has been a long time coming. I've been wanting to share my favorite sports bras with you because I know that finding a good one is so important! I'd love to hear about your favorite sports bras too!
This sports bra is comfortable, lightweight, and fits well. I wear it for medium-intensity cardio and weight workouts. Basically, it's my 'go-to' sports bra that I wear most often.
I'm a 32 D bra typically, and I wear a size Medium in this bra.
Amazon sells them too and offers them in other colors.
I like this kind of sports bra also, but more for just weight training. I also wear this as a regular bra with clothes because it's also so lightweight and seamless. I adore this lemon color!
This is my absolute favorite sports bra to run in. It's comfortable and you can adjust the straps. No more doubling up on sports bras to run. It's solid in color, I just wanted to show you the 'V' back and wide closure. It comes in sizes 30B - 44C.
This bra is designed for women with 30C - 40D cups and is great for running and other high-impact sports. It's kind of a lot of material, but really keeps the girls in place!
I hope this helps! Do you have a favorite sports bra?
:: SHOP SPORTS BRAS ::
Affiliate links used.
Monday, 16 June 2014
The Evidence Supporting Heart Failure Care Management
"Yawn!" |
They all involved some version of risk stratification and a combination of telephonic and in-person nurse-based care management.
And they all worked.
Which is why the Annals of Internal Medicine could have saved itself a lot of time and effort by simply asking the PHB for a summary. Instead, it did the next best thing and published this meta-analysis by Feltner et al. The authors pooled the data from 47 randomized clinical trials and found that both in-person and telephonic nurse-led disease care management reduced readmissions to a statistically significant degree.
Takeaways:
1. This is another example of old news not making reaching the elite ruling classes of Academikstan until well after the fact.
2. For my colleagues in the medical home movement, take note: achieving financially relevant outcomes will depend on focusing care management where it will have greatest impact. Instead of managing all patients with heart failure (for example), start by managing the patients at risk of (re) hospitalization. That's where the return-on-investment gold can be mined.
Image from Wikipedia
Sunday, 15 June 2014
Bikini Contest Prep // 3 Weeks Out
With just 3 weeks left until my bikini contest, I'm finally feeling confident that I'll be able to hold my own on stage. This is such a big relief! It just goes to show that over time, with the right diet and exercise, how much you can change your body. Of course, I'd love to win, but in reality, just changing my physique to this degree and making it to the contest without chickening out is a big win in my book! And eating clean for so long is a big deal. I'm a girl who LOVES her sweets! Chocolate, ice cream, ice-tall 2-pump mocha from Starbucks, cheesecake, chocolate chip cookies . . . I digress.
I was thrilled to learn I got to have a specific cheat meal on Saturday night at a restaurant! I haven't had a true "date night" in a very long time, so this was good news. Even though there was no alcohol involved. The meal I was allowed to have was steak (no oil and no butter) I ordered a 6 oz filet, plain baked potato, and dessert (I got the molton chocolate cake) and it was awesome. But, I was so uncomfortably full after my meal for about two hours that my stomach hurt.
I sent pictures to my trainer on Saturday afternoon before the meal and again on Sunday morning, but we didn't notice much change. These pictures are from Saturday- exactly 3 weeks out from my contest. My stomach is coming down and tightening up and my legs and arms have more definition.
Even though there was no discernible difference between before and after the cheat meal, I do notice HUGE changes from when I started this journey to now. If you've been following along, you know I started focusing on getting in shape in February and began by working out on my own and eating better. At that time, I measured time by how long I'd been working out so 'Week 1' was my first week back in the gym and 'Week 3' was 3 weeks later. Now, I'm counting backwards from my contest date, so '3 Weeks Out' means I have 3 weeks until my contest. I've been at this for about 6 months now and been working with my trainer since April. I've been on a strict meal plan for about 9 weeks.
CONTEST DETAILS & PREPARATIONS
I registered for the contest this weekend. I will be competing in the BIKINI division in two categories: 1) Novice (for first-timers or anyone who has competed previously, but not won), and 2) Masters (over age 35) - I'm 39.
My bikini has been ordered, but I still need to go for my final fitting. I have my heels. The pic below is just a sample suit. My stage suit will be aqua with different connectors and aqua-colored beading. I tried on this black top (a size 'C' because the 'D' was too much fabric).
I need to figure out if I'm doing my own hair and makeup or hiring someone. The contest has a hair and makeup person I need to check out.
I also need to make sure I'm signed up to receive my spray tan before the show. I am going to a tanning bed about once a week to get a base tan. *Update: Thank you for smacking some sense into me! I read the comments below and realized what a bad idea going to a tanning bed is, so no more.
Thank you again for all of your positive comments and support! It really encourages me! If you have any questions, please leave a comment. I will answer in the comments and also use your comments in future blog posts so I can expand and answer in more detail.
I do have an "after contest" plan to share with you soon too!
You can follow me on Instagram:
Take care of you!
Friday, 13 June 2014
Thursday, 12 June 2014
The Patient Centered Medical Home PCMH Gets On Base with Increased Quality in the Real World
Getting to first base |
The Population Health Blog likes it too. But first, let's look at the study itself.
The Taconic Independent Practice Association participated in a multi-commercial insurer medical home program. For each patient enrolled in an NCQA Level 3 primary care home, the IPA was offered $2 to $10 per patient per month.
Since not all of the 675 IPA practices created medical homes in the 2008-2010 time frame, researchers were able to compare the quality of care for the approximately 27,000 patients attributed to the medical homes versus the approximately 64,000 patients attributed to usual care settings. While they were at it, they also evaluated the quality impact of having an electronic health record (all medical home practices had one, but not all users of electronic health records were medical homes) vs. having a paper record. Quality was determined by examining a subset of NCQA-based measures of recommended routine screening tests and care of persons with diabetes, asthma and (for children) pharyngitis.
While the impact of being in a medical home was not a home run, it definitely got on base.
Over the three years of the study, the medical home practices' measures diverged from the other two groups by an average of a 7% vs. paper and 6% vs. EHR. While none of the practices hit 100%, and not all of the differences were statistically significant, if an EHR-based clinic was able to hit (for example) a "72%" quality measure, the medical home was"79%" (mammogram screening).
As one more gauge of its impact, as time went on, the spread of the data grew over time as medical homes outpaced the usual care practices.
The authors correctly point out that the study was observational and that there could be hidden factors other than the presence or absence of a medical home that could be biasing the data. While the authors did everything they could to statistically "neutralize" the impact of unequally distributed patient or practice factors, the study process is not perfect.
This was also in a commercial insurance setting. We don't know if Medicare patients would gain the same benefit.
The PHB will also point out that the NCQA's one-size-fits-all measures are intermediate in nature and are imperfectly tied to long term outcomes. They also fail to account for patient preferences.
On the other hand, the PHB likes this because it was a huge "real world" study involving hundreds of clinical practices taking care of tens of thousands of patients over three years. It helps the PHB put things in perspective by showing that the team-based care management of the medical home can have a discernible impact on quality.
Unfortunately, there is nothing on the cost of care. The PCMH is still struggling to prove that it "saves" money; the PHB says health care consumers will get what they pay for and - aside from a selected high-risk subpopulation - the medical home offers high value at a reasonable additional cost. The commercial insurers got their money's worth from the Taconic IPA.
While the authors don't specifically call it out, there doesn't appear to have been a large impact by the EHR on the quality of care in the real world. Compared to practices with paper records, the impact of the EHR seemed to be scant.
Wednesday, 11 June 2014
Has Obesity Research Failed?
I frequently encounter the argument that obesity research has failed because it hasn't stopped the global increase in obesity rates. According to this argument, we need to re-think our approach to obesity research because the current approach just isn't working.
Grant funding for obesity research keeps increasing in the US, and the prevalence of obesity also keeps increasing*. What gives? Maybe if we just scrapped the whole endeavor we'd be better off.
Let's take a closer look at this argument and see how it holds up.
Why Do Research?
There are two fundamental reasons why we do research:
Read more »
Grant funding for obesity research keeps increasing in the US, and the prevalence of obesity also keeps increasing*. What gives? Maybe if we just scrapped the whole endeavor we'd be better off.
Let's take a closer look at this argument and see how it holds up.
Why Do Research?
There are two fundamental reasons why we do research:
- To gather accurate information about the natural world. This information is intrinsically valuable because we like knowing how the world works, and it may eventually have practical value that's not immediately obvious.
- Practical applications. We want to solve problems and improve our lives.
If we want to determine whether or not obesity research has failed, we should evaluate it using those two metrics.
Has Obesity Research Gathered Accurate Information?
Insulin for Persons Already on Metformin: A Population Health Perspective
As most population health providers know, diabetes guidelines tend to focus on shorter-term or "intermediate" outcomes, such as average blood sugar levels or A1c levels. That's because these short-term measures are surrogates for "long term" outcomes, such as blindness and kidney disease.
Two inconvenient facts have complicated the focus on intermediate outcomes:
1) Once a threshold has been achieved, lower short-term blood glucose control doesn't necessarily lead to better long term outcomes;
2) The side effects of drugs - that otherwise work quite well at achieving short-term blood glucose control - may outweigh any long-term advantages.
And now a just-published research study from JAMA raises the possibility that insulin has additional long-term side-effects.
According to diabetes mellitus treatment guidelines from organizations like the American Diabetes Association, the first medication option for Type 2 diabetes should be metformin. If that doesn't work, the ADA suggests that there are several options for a second drug, including one of several sulfonylureas (glyburide, glipizide or glimepiride) or insulin.
Sulfonylureas are pills, but have a reputation for not leading to the same level of diabetes control as insulin. Unfortunately, while it's a more potent means of blood glucose control, insulin has to be injected.
Further details on the methodology are below.* Basically, Veterans Affairs electronic records were "mined" to find thousands of persons with diabetes who were using metformin and then had to start either insulin or a sulfonylurea. Propensity scoring was then used to create two otherwise similar cohorts of patients and neutralize the impact of the diabetes control and disease burden.
2436 patients on metformin and insulin were compared to 12,180 patients on metformin and a sulfonylurea.
After a median of 50 months of observation, the risk of a heart atttack, stroke or death from all causes was 43 per 1000 person-years in the insulin group vs. 33 in the sulfonylurea group. That difference was statistically significant. When deaths alone were examined, there was likewise an increased number in the insulin group (34 per 1000 person years) vs. the sulfonylurea group (23 per 100 person years).
The Population Health Blog's take:
This study raises the possibility that, among persons with diabetes on metformin, insulin is associated with an increased absolute risk of about 1 per 100 person years (10 per thousand person years, or one person out of a hundred persons followed for one year) of heart attack, stroke or death vs. the sulfonylurea pill. Yikes.
Before we ban insulin in this population, however, the PHB is reminded that this was an observational study. As an accompanying editorial points out, propensity scoring is not perfect and other unmeasured and confounding factors in the population could be biasing the results. Short of a randomized clinical trial, there are other databases that could be mined the same way. That includes those of the population health vendors, who also have a stake in risk stratification and long-term follow-up.
In the course of coaching persons with diabetes on metformin who are considering insulin, the additional risk of heart attack, stroke or death should be raised. While the study above isn't perfect, the possibility is something that health care consumers need to weigh.
++++++++++++++++++++++
*Methodology:
Veterans 18 years and older who.....
1) were followed for at least two years with provider visits every 6 months,
2) who had been placed on metformin and regularly used it between 2001 and 2008,
3) had one year of records prior to the first prescription for metformin and
4) were not on dialysis or in hospice
Once a vet filled a prescription for either insulin (long acting, premixed or short/long acting) or a sulfonylurea (glyburide, glipizide or glimepiride) and continued it for 6 months, their records became eligible for the study. Patient records were excluded if there was no follow-up for six months, if the meformin was stopped for 3 months or a third diabetic drug was prescribed.
52% (approximately 92,000) of the 178,000 vets on metformin did not use another medicine. Most were men (95%) and white (70%). 2948 were started on insulin and 39,990 started a sulfonylurea. The persons placed on insulin had, on average, worse diabetes control (A1c 8.5% vs. 7.5%) and a higher disease burden.
Two inconvenient facts have complicated the focus on intermediate outcomes:
1) Once a threshold has been achieved, lower short-term blood glucose control doesn't necessarily lead to better long term outcomes;
2) The side effects of drugs - that otherwise work quite well at achieving short-term blood glucose control - may outweigh any long-term advantages.
And now a just-published research study from JAMA raises the possibility that insulin has additional long-term side-effects.
According to diabetes mellitus treatment guidelines from organizations like the American Diabetes Association, the first medication option for Type 2 diabetes should be metformin. If that doesn't work, the ADA suggests that there are several options for a second drug, including one of several sulfonylureas (glyburide, glipizide or glimepiride) or insulin.
Sulfonylureas are pills, but have a reputation for not leading to the same level of diabetes control as insulin. Unfortunately, while it's a more potent means of blood glucose control, insulin has to be injected.
Further details on the methodology are below.* Basically, Veterans Affairs electronic records were "mined" to find thousands of persons with diabetes who were using metformin and then had to start either insulin or a sulfonylurea. Propensity scoring was then used to create two otherwise similar cohorts of patients and neutralize the impact of the diabetes control and disease burden.
2436 patients on metformin and insulin were compared to 12,180 patients on metformin and a sulfonylurea.
After a median of 50 months of observation, the risk of a heart atttack, stroke or death from all causes was 43 per 1000 person-years in the insulin group vs. 33 in the sulfonylurea group. That difference was statistically significant. When deaths alone were examined, there was likewise an increased number in the insulin group (34 per 1000 person years) vs. the sulfonylurea group (23 per 100 person years).
The Population Health Blog's take:
This study raises the possibility that, among persons with diabetes on metformin, insulin is associated with an increased absolute risk of about 1 per 100 person years (10 per thousand person years, or one person out of a hundred persons followed for one year) of heart attack, stroke or death vs. the sulfonylurea pill. Yikes.
Before we ban insulin in this population, however, the PHB is reminded that this was an observational study. As an accompanying editorial points out, propensity scoring is not perfect and other unmeasured and confounding factors in the population could be biasing the results. Short of a randomized clinical trial, there are other databases that could be mined the same way. That includes those of the population health vendors, who also have a stake in risk stratification and long-term follow-up.
In the course of coaching persons with diabetes on metformin who are considering insulin, the additional risk of heart attack, stroke or death should be raised. While the study above isn't perfect, the possibility is something that health care consumers need to weigh.
++++++++++++++++++++++
*Methodology:
Veterans 18 years and older who.....
1) were followed for at least two years with provider visits every 6 months,
2) who had been placed on metformin and regularly used it between 2001 and 2008,
3) had one year of records prior to the first prescription for metformin and
4) were not on dialysis or in hospice
Once a vet filled a prescription for either insulin (long acting, premixed or short/long acting) or a sulfonylurea (glyburide, glipizide or glimepiride) and continued it for 6 months, their records became eligible for the study. Patient records were excluded if there was no follow-up for six months, if the meformin was stopped for 3 months or a third diabetic drug was prescribed.
52% (approximately 92,000) of the 178,000 vets on metformin did not use another medicine. Most were men (95%) and white (70%). 2948 were started on insulin and 39,990 started a sulfonylurea. The persons placed on insulin had, on average, worse diabetes control (A1c 8.5% vs. 7.5%) and a higher disease burden.
Monday, 9 June 2014
Bikini Contest Prep // 4 Weeks Out
We're in the final stretch now, and I'm really starting to look forward to the end. This last two weeks I had to kick it into high gear to try to lose more weight and body fat. I did it by upping the intensity of my cardio and staying as strict as possible on my diet. As of today, I weighed 106 (at the gym, 103-4 at home) and am at 17% body fat (down from 109 gym pounds and 19% body fat two weeks ago). I started this journey at 25% body fat and 110 pounds (at home). Go here to see my pics at 15 weeks out.
For cardio, I'm doing 45 minutes, 5 days a week and it's usually on the treadmill at a 15 incline and a speed of 2.7-3.0. If I need a break, I lower the incline for a couple minutes, then ramp it back up. I'm also doing more ab exercises (at the end of each workout). I use my iPod and iPhone to pass the time and also met a woman who also does cardio at the same time so we'll chat. For abs, I typically do 2 ab exercises 4 times and 20 reps. I'm working with my trainer about 4 days a week.
I'm still amazed at the level of physical effort all this training takes. It's exhausting. I realize now how intense you have to train and diet to get in the kind of shape for a NPC bikini competition. I do love the results and how my clothes fit (down to a size 24 jean - was a 26).
I still need to lose a few more pounds in the next four weeks. Last recap, I wrote about how much mahi mahi I was eating, but I got concerned about the mercury levels, so now I'm incorporating grilled chicken salads with fat-free dressing for a couple meals and eat fish for one meal.
Lately, I have been craving all kinds of food and thinking more about when this is done, how nice it will be to not be SO strict with my food. I ate a pint of Gelato on Saturday (while watching Orange Is The New Black Season 2 marathon- are y'all hooked?!) and really enjoyed it. Don't tell my trainer!
The black striped bikini was taken at 5 weeks out.
The aqua bikini pic was taken at 4 weeks out.
I go for my bikini fitting tomorrow! p.s. These bikinis are from Victoria's Secret. ;)
The Turing Test Falls: Implications for Health Care Decision Support
In the futuristic movie Blade Runner, Detective Rick Deckard's (played by Harrison Ford) skill at "retiring" renegade robotic replicants depends on a series of trick questions that are designed to detect an "empathic" response. While the soulless robots routinely fail the test, the highly advanced Nexus-6 models still seem to be eerily human. While Deckard violently terminates three of the robots, lingering questions over just what is "human" leads him to fall for vulnerable sexy replicant Rachael.
While the Population Health Blog ponders that, along comes the news that a Russian chatbot computer passed the Turing test. More than 30% of the humans who engaged in a text-only "conversation" with the program thought it was being controlled by a 13 year old boy. Not only was the computer able to organize facts and sentences, it also responded with the subtle nuances that underlie typical "human" communication.
While the PHB is weirded out, it is not surprised. In the book The Second Machine Age, authors Erik Brynjolfsson and Andrew McAfee note the doubling of computers' processing power can be likened to the ancient story of doubling wheat seeds on the squares of a chess board. They point out that the amount of wheat (or processing power) can be grasped until you get to the "second half" of the board: that's when the amounts become staggering and the implications start getting weird.
They point out that computing power has now entered that second half. Quadruped "mule pack" machines can carry payloads across unfriendly landscapes, entire factories can manufacture complex items at a fraction of the cost and Watson can win Jeopardy matches.
And now, Turing has fallen.
This is good news for health care. "Second half" decision support in electronic health records is better able to focus on a more likely differential diagnosis, suggest a more accurate series of tests and tailor treatment at the point of care. The good news is that medicine will finally become faster, better and cheaper. While some may fret about the loss of the "human touch" (or jobs) in this brave new world of the doctor-patient relationship, Brynjolfsson and McAfee point out that when human intelligence is combined with the resources of high performing information technology, the product is better than either alone. For example, a chess master plus a high-end chess program can beat either alone.
The same will be true in medicine: smart doctors plus nuanced health information technology will be better than either alone.
Just like in Blade Runner. Thanks to each other, both Deckard and Rachael are better... humans.
Image from Wikipedia
While the Population Health Blog ponders that, along comes the news that a Russian chatbot computer passed the Turing test. More than 30% of the humans who engaged in a text-only "conversation" with the program thought it was being controlled by a 13 year old boy. Not only was the computer able to organize facts and sentences, it also responded with the subtle nuances that underlie typical "human" communication.
While the PHB is weirded out, it is not surprised. In the book The Second Machine Age, authors Erik Brynjolfsson and Andrew McAfee note the doubling of computers' processing power can be likened to the ancient story of doubling wheat seeds on the squares of a chess board. They point out that the amount of wheat (or processing power) can be grasped until you get to the "second half" of the board: that's when the amounts become staggering and the implications start getting weird.
They point out that computing power has now entered that second half. Quadruped "mule pack" machines can carry payloads across unfriendly landscapes, entire factories can manufacture complex items at a fraction of the cost and Watson can win Jeopardy matches.
And now, Turing has fallen.
This is good news for health care. "Second half" decision support in electronic health records is better able to focus on a more likely differential diagnosis, suggest a more accurate series of tests and tailor treatment at the point of care. The good news is that medicine will finally become faster, better and cheaper. While some may fret about the loss of the "human touch" (or jobs) in this brave new world of the doctor-patient relationship, Brynjolfsson and McAfee point out that when human intelligence is combined with the resources of high performing information technology, the product is better than either alone. For example, a chess master plus a high-end chess program can beat either alone.
The same will be true in medicine: smart doctors plus nuanced health information technology will be better than either alone.
Just like in Blade Runner. Thanks to each other, both Deckard and Rachael are better... humans.
Image from Wikipedia
Thursday, 5 June 2014
More Big Insights on Big Data
Given the data, what are her chances of getting breast cancer? |
As noted previously, "big data" is the use of statistical associations ("predictors") in a) large and b) disparate data sets to gain insights at the individual level ("outcomes"). For example, a physician could know the likelihood - based on demographic, clinical and economic inputs - that a particular patient won't fill a prescription. As an other example, the PHB spouse could know the likelihood - based on prior active-passive behaviors, incentives and maternal upbringing - the likelihood, despite numerous reminders, that her husband will "forget" to take out the trash.
It's important to recall that big data is not about causality. Just because living in a certain zip code is an independent predictor of obesity (for example) doesn't mean living in [insert name of town] causes residents to be fat. Big data is "agnostic" about the cause, but that doesn't mean Big Data Architects (BDAs) can't use the information.
According to the author, the road from the promise to the reality of big data will be lined with:
1. generalizability, or being confident that the populations used in big data studies are similar to the populations where their lessons are being applied. Propensity matching or scoring is a good step in that direction;
2. automation, so that multiple questions can be answered simultaneously by many users;
3. "data refreshes," so that associations can be retested on repeated basis as new data come on line;
4. ease-of-use, so that even an orthopedist could use the software and understand the outputs.*
Politically, we'll also need to get
5. the owners of data warehouses - including the electronic health record vendors and insurers - to agree on either a) common data formats or b) methods that allow for the interpretation of data regardless of the format. An example of the latter the use of an order, entry or insurance claim for supplemental oxygen therapy as a marker of poor health status.
6) a resolution of our absolutist privacy "impasse.""De-identification" of patients' information makes it possible, but never guaranteed, to keep personal health information secure.
*okay, the New England Journal author didn't poke fun at the orthopedists by saying that, but the PHB couldn't resist. By the way, one way to do this would be to have the outputs be in pictures.
Image from Wikipedia
Wednesday, 4 June 2014
DITCH THE BITCH
Life is hard and challenges are put in our path almost daily. It is those life events that occur over several days, months, or even years that can zap the crap out of us. I realize that it can be difficult to remain positive or refrain from “bitching” for lack of a better word about the circumstances of life that can bring us down. I have journeyed through the ups and downs of what has felt like huge ocean waves and have been brought to my knees on several occasions, and yes, I am guilty of a bitch or two or more. It can feel frustrating, hurtful, painful, and unfair when we are tossed into the sea of confused human emotion and circumstances.
What I will share is that “bitching” about it will not change a thing, and in fact, usually makes life feel worse as negative emotions try to take over our very being. This is when we tend to lash out, make poor choices, and even grab for those comfort foods that are supposed to fix everything when life feels bigger than us. Life does not come with an “easy” button, but our successes in life are achieved through how well we weather the storms that slap up us in the face and knock us on our butts.
It is one thing to be physically strong, but I will share that mental strength is what will carry us through life. Life is “10 percent what happens to us and 90 percent how we respond to it” so if we are bitching about the circumstances and wearing that “why me?” attitude, that eliminates all possibilities to learn and grow from the situation. “Why or poor” me creates a life of bitterness and resentment, and can scar deep and for many years. Looking at a situation and saying “I do not like this, BUT what can I learn from this to become a better person” will bless our lives in so many ways. We will never be able to see the end game and that is where faith comes into the picture. We can help with the outcome through our attitude however. If we “Ditch the Bitch” and take on a mental game of “I CAN get through this” no matter what, then you have won already.
This applies to all areas of life including getting healthy, weight loss, illness, overcoming injury, job loss, and broken relationships just to name a few. We are all here living a life that we think should happen for us, but we truly do not have control of so many things in this life. Realizing that we can only control our responses to the uncontrollable is what creates a better self, a healthier and stronger person overall. Keep in mind that when we are living this journey of life and reaching for goals, it is not in the bitching that the positive stuff happens. Time to “Ditch the Bitch” and Stay Healthy!
Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list. If you are inspired, LIKE my entry, leave a comment and I look forward to responding!
Darla
Subscribe to:
Posts (Atom)