A Health Care Clerisy?

We're here and we've figured it out

The Population Health Blog is reading Joel Kotkin's "The New Class Conflict." While it hasn't gotten through all of it, the central premise is a refreshingly alternative explanation for our
national malaise. 

It's less a matter of conservative vs. liberal ideologies that are leveraging class warfare. Rather, it's us vs. an unholy alliance of the new internet-media Oligarchs and their fawning expert clerisy.

"The New Class Conflict" doesn't dive into the implications for health reform. That naturally prompted the PHB to apply Mr. Kokin's lens to our healthcare expert class. 

Let the readers decide if this shoe fits. It may be paranoid, but it sure is fun to think about.

A quick word on the Oligarchs: these are the fabulously wealthy who dominate Silicon Valley.  They truly believe their template for success can change society for the better. They are very willing to deploy their new-found billions to promote their progressive, technological and green mindset.  The fact that their solutions are enormously self-serving makes them no different than the industrial barons of the 1930s.
   
Enter their health reform "clerisy" allies. They are made up of a growing academic, media, not-for-profit and government-worker technocratic class.  Armed with their science-based insights, they are advocating, lobbying, funding and regulating away an old health care order previously dominated by church, lay-business and volunteer organizations. Markets and ownership are being replaced by the priestly wisdom of an unelected elite presiding over a regulated utility. And they are being cheered on by their liberal-progressive and highly creative allies who dominate the old and new social media.

Opposing views are not only unwelcome but drowned out by a self-reinforcing echo chamber of this clerisy's group-think. Unapproved thoughts on, for example, the old-fashioned ability of health insurers to pool risks, the virtues of fee for service to incent access and the merits of small physician-owned private practices are tut-tutted as sadly misinformed. The few who rise above the noise are labeled as in the pockets of fat cats or being right-wing ideologues. 
   
And who should be surprised that the oligarch's interest in information technology dominates their health care agenda? Electronic records will save health care from itself, decision support will usher in a new clinical wisdom and big data today will lead to miracles tomorrow.  And by the way, if that leads to additional billions flowing to the oligarchs, all the better.  All that remains is figuring out which city they should buy an estate in so that they can run for elected office and legislate a single payer system modeled after Microsoft and powered by Google.

Their hardest job?  Persuading consumers as well as front-line health care workers to "work against their material interests or traditional beliefs." Think about paying more for energy, giving up control of education  and letting the NSA troll Facebook's data for bad behavior. In the healthcare space, patients must agree to consume less health care with health insurance they don't want while letting more of their personal data be used. Front line providers have to do more with less income, less control and less prestige.
. 
Oh, and the clerisy and their oligarchs remain personally insulated against the very policies that they promote for everyone else. If they need health insurance, it won't be a Bronze plan from an Exchange any more than they'll give up their big cars, private schools and internet privacy.

It's the 1% alright, but they're hiding in plain sight.

Frightening thoughts.

Food Reward Friday

This week's lucky "winner"... donuts!!

Krispy Kreme donuts being made.  Hopefully this image isn't appetizing enough to make you want donuts.

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The Iron Triangle of mHealth Apps Due Diligence: What CEOs and Boards Need to Know

As the Population Health Blog's medSolis CMO expertise in mHealth expands, it can't help but admire the infectious "can-do" optimism of its "app" programmer-developer colleagues and competitors. Even if healthcare is a morass of dreary economics, regulatory meddling and dysfunctional politics, these entrepreneurs really do believe that "there is an app for that!"

And neither are leaders in hospitals, clinics, provider systems, insurance companies, medical device manufacturing and population health immune from the developers' enthusiasm. "Apps" are being built or bought with the belief that they'll lower costs, create profits, increase quality, promote satisfaction, build brand, secure customer loyalty and generate invitations to White House conferences.

The PHB agrees. Apps can certainly achieve many of these outcomes, and it is looking forward to seeing the Roosevelt Room for itself in the not-too-distant future.

But that doesn't mean that CEOs, Boards and investors shouldn't be wary of how the healthcare "Iron Triangle" should factor into their "app" due diligence.

Old fashioned management experts will recognize the concept. They know that any project involves trade-offs between cost, quality and access. Improve any single dimension and the other two will suffer.  Improving two means having to compromise on the third. 

In other words, there are inevitable trade-offs.

Population health service providers are well acquainted with this. For example, launching a diabetes initiative means balancing the costs of the program, the intensity with which the enrollees will be managed (quality) and outreach with a span of services as well as associated risks that will be addressed (access). Accepting a lower fee per patient may lead to compromises in quality. Insisting on a greater span of managed risks could lead to higher costs or cut-backs in the level of patient counseling.

Which brings the PHB to mHealth. To the PHB, the three iron sides to configuring an app are the same:

Cost: This is not only a function of the nuts and bolts of programming, hosting and updating the app, but includes the additional economic burden of maintaining up-to-date security for the users' personal health information. There's also the added cost of updates.

Quality: This includes dimensions such as symptom control, condition management, promoting patient safety, reducing identifiable risks and measuring outcomes for quality improvement as well as research.

Access: The interface has to be speedy and intuitive, meeting consumerist expectations for ease-of use. That includes connectivity, screen loading, minimal manual inputting and efficient asynchronous communication.

How should CEOs and Boards think about apps? 

They should think about cost, quality and access and understand the inevitable trade offs that underlie the sweet spot of a successful app.

Costs will never go away. But smart app developers are using off-the-shelf, open-source as well as modular programming with (secure and encrypted) web-based hosting. Shortchanging IT support or security risks not only crashes and hacking, but could limit the end-users' ability to manage the continuum of health risks (quality) in a user-friendly and speedy manner (access).

Quality is important but judgment is necessary in understanding the secret sauce that links quality, behavior change and risk. It's possible to "overdo" condition management with a glut of care options, unnecessary attention to every risk, over-engineered branching logic and over dependence on human inputs. 

Access will be what the end-user cares the most about, including ease of use in a pleasing interface. Streamlining this too much, however, could lead to shortcuts that compromise optimum condition management or require additional costly information technology.

Bottom line?

If a company's senior leadership or Board of Directors is grappling with an app-based product launch, they need to understand the inevitable cost-quality-access trade-offs that were made in the course of its design.  If the cost is low compared to benchmarks, ask about the compromises in quality or access that were made.  If the developers claim that the condition management is the highest quality, scrutinize development costs and how access could suffer. 

Accordingly, the best apps on the market will be those that strike the right balance between cost, quality and access.

Trading away Health: Reflections on an HIA of a trade agreement”

Guest post by Fiona Haigh:

The HIA team at CHETREhas been working with a group of Australian academics and non-government organisations to carry out a health impact assessment (HIA) on the Trans Pacific Partnership Agreement (TPP) negotiations. The report has attracted a lot of attention and in general has been a different experience from the typical HIAs that we are involved in. We thought it would be interesting to share with the HIA community a few reflections on our experience.

We weren’t commissioned to do this HIA- a small group of us thought it would be a good and interesting thing to do and we somehow managed with some support from CHETRE and the Public Health Association of Australia keep it going. The support from CHETRE enabled us to bring in Katie Hirono to do a lot of the work on it and we were supported by a group of experts and advocacy groups who contributed their expertise and advice. There were some technical challenges to do with trying to do an HIA on something that is being kept secret. We had to base our assessment on leaked documents on wikileaks and advice from academics working in the area and policy experts. We also faced the challenge of trying to predict likely future public health policies that could be impacted on by the trade agreement (since it won’t affect current policies). We approached this by working with policy experts to identify likely future public health policies in our scoped areas of focus that would be impacted on by the TPP.

We also walked the talk of taking a participatory approach, which meant sharing power with the technical advisory group and the advocacy groups that we worked with throughout the process. We feel that this has worked really well- it meant that we focused on issues they identified as important and we have produced a report that they have been able to immediately use for their advocacy. Without them I’m pretty sure this report would not be having the impact it has had so far. The report is being talked about on the front pages of major newspapers, there have been multiple radio interviews, a social media campaign led by CHOICE (the main consumer advocacy group in Australia), lots of tweets and perhaps most satisfying of all we’ve been labeled scaremongers in a press release from the minister for trade and investment - we must be doing something right!

NO ONE BUT YOU CAN MAKE HEALTH HAPPEN

In this world of comparison and getting pissed off at her or him for seeming to accomplish everything, and then spewing “what’s your excuse” in our faces, it’s no wonder women and men alike are throwing up their arms in frustration and happily giving a bird salute attitude at achieving fitness goals.  

Put on the brakes here and look at what has happened.  Letting others control what is best for our health and fitness is out right wrong, and does nothing for us.  That being said, why are we allowing people or media so much control over our decision making to create a healthy, happy life when they have little to no concern or care for us?  Why so pissed about it?  What it comes down to is that no one but you can make health happen.  You know that saying that goes, “whether you do or you do not, you are right.”  Well, that is true and the choice to get healthy lies squarely on your shoulders.  There is no amount of jealousy, blaming others, or putting up defensive posture because others are doing what you are not willing, that will get you closer to your health and fitness goals. 

It does not matter how busy you are, I am, he or she is, because we all can say that we are too busy to carve out that very important exercise hour, and plan and prep healthy food time.  The “what’s your excuse” phrase does hit hard and can ruffle the feathers, especially when it comes from family and friends.  When it comes from the media, it is easier to be judgmental and hide behind our computers commenting on how cushy her or his life is and how they have the time to get it done.  I say bullshit to that and start accepting responsibility for our actions, stop comparing to others, and who gives a crap what anybody’s excuse is.  What is important are the excuses that we are making and why.  It is time to tune into self and let go of insignificant negative drama that weighs down our positive minds.  No one but you can make the choices to move past the excuses and the feelings that keep you from getting healthy. 

Darla Leal, Fit at 50

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Build Your Own Yogurt Maker, Sous-vide Cooker, and All-purpose Fermenter for $40

I make a half gallon of yogurt, twice a month.  I like making my own yogurt for many reasons, but it's a bit of a pain.  Since I make large batches, I can't use a standard yogurt maker.  I often get distracted and over-heat the milk, and the method I use to incubate the yogurt is wildly inefficient (my beloved Excalibur dehydrator).  I also need a constant warm temperature for various other fermentation projects, and that's often difficult to achieve with the tools I have.

I finally found a better solution: a temperature controller that accurately regulates the temperature of a slow cooker by turning an outlet on or off.  I simply set the temperature of the controller, place the temperature probe into the slow cooker, and plug the slow cooker into the temperature controller outlet.  The slow cooker then stays at whatever temperature I want.  Here's what the temperature controller looks like:

Once built, the temperature controller with or without the slow cooker can be used for a variety of other tasks (including regulating cooling devices).  Here are some ideas that come to mind:

• Sous-vide cooker
• High-capacity yogurt maker
• Bread dough riser
• All-purpose thermophilic fermenter (e.g., for tempeh, natto, koji)
• Beer/cider/wine fermentation temperature controller
• Kegerator controller
• Freezer-to-fridge conversion
• Egg incubator
• Soil temperature controller for seed starting

Don't worry, I'm not turning into a food blogger.  But this sous-vide-cooked
chicken I made with my DIY temperature controller was pretty tasty.
I used this recipe from NomNom Paleo.

You can build the whole thing for about $40, including the slow cooker.

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Health Impact Assessment of the Proposed Trans-Pacific Partnership Agreement

An HIA of the Trans-Pacific Partnership Agreement (TPP) has just been released, authored by Katie Hirono, Fiona Haigh, Deborah Gleeson, Patrick Harris and Anne Marie Thow.

From the media release:

Report finds medicine affordability, public health policies at risk in Trans Pacific Partnership

A report released today by a large team of academics and non-government health organisations reveals that the Trans-Pacific Partnership Agreement (TPP) poses risks to the health of Australians in areas such as provision of affordable medicines, tobacco and alcohol policies and nutrition labelling. Many public health organisations have been tracking the progress of the TPP negotiations over the past several years and have expressed concerns about the potential impacts and lack of transparency. 

“The TPP includes provisions that don’t just affect trade. They affect the way the Government regulates public health,” said Michael Moore, Chief Executive Officer (CEO) of the Public Health Association of Australia (PHAA). “In many areas – such as nutrition labelling - it’s already a struggle to implement effective policies that promote health. If certain provisions are adopted in the TPP, this will be another hurdle for organisations seeking positive public health outcomes.”

The report also argues that: “The TPP risks increasing the cost of the Pharmaceutical Benefits Scheme (PBS), which is likely to flow on to the Australian public in terms of increased co-payments (out-of-pocket expenses) for medicines”. An increase in co-payments risks declining public health and increasing hospitalisations, particularly for people who are already disadvantaged.

A team of researchers from UNSW Australia, Sydney University and La Trobe University conducted the health impact assessment based on leaked documents from the trade negotiations.

“In the absence of publicly available current drafts of the trade agreement, it is difficult to predict what the impacts of the TPP will be,” said Dr Deborah Gleeson, one of the report’s authors. “In the study, we traced the potential impacts based on proposals that have been - or are being - discussed in the negotiations. But the only way to properly assess the risks is to allow a comprehensive health impact assessment to be conducted on the final agreement before it gets signed by Cabinet.”

The report offers a set of recommendations to the Department of Foreign Affairs and Trade to reduce the likelihood that the TPP will negatively impact health in Australia. Such recommendations include excluding an investor-state dispute settlement (ISDS) mechanism, and including strong wording to ensure that public health takes priority where there is a conflict with trade concerns. The report also recommends that Government change its approach to conducting trade agreements, for example by publishing draft texts and negotiating positions on issues of public interest.

Trade negotiators are meeting next week in Hawaii. The Minister for Trade and Investment, Andrew Robb, has said he anticipates the negotiations will wrap up within the next few months.

“It’s vitally important that health is given high priority in the final stages of the negotiations,” said Lynn Kemp, Director, Centre for Health Equity Training, Research and Evaluation. “We urge the Australian Government to consider these issues seriously.”

The HIA report can be accessed here.