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Don Berwick, candidate for Governor of Massachusetts, speaks with the Health Business Blog

Don Berwick (D), candidate for Governor of Massachusetts

Don Berwick (D), candidate for Governor of Massachusetts


In this podcast interview, Don Berwick, Democratic candidate for Governor of Massachusetts and former head of the Centers for Medicare and Medicaid Services, discusses his views on healthcare with healthcare business consultant David E. Williams, president of the Health Business Group. This is the fifth in a series of nine in-depth interviews with the candidates. For a complete schedule and an explanation of the questions visit the intro post.

Excerpts from the interview are below. The full transcript is available here.

Question 1: Does Chapter 224 represent the right approach to addressing rising health care costs? If not, where does it miss the mark and what would you do differently?

“It’s directionally correct. It sets some goals for cost containment in the state. It encourages coordinated behavior among caregivers. It’s a step in the right direction. I am hopeful about it, but its major problems are that it’s primarily voluntary.”

“It may need more teeth. It’s so urgent to get healthcare costs under control in the Commonwealth without harming a hair on a patient’s head.”

“The state should pursue what, in my former role, I used to call the Triple Aim: better care, better health, and lower cost through improvements.”

“I’m the only gubernatorial candidate who has put single-payer as an option, potential option, for the state on the table.  I would like to see us move very swiftly to understand whether and how we could move into a single-payer environment.”

Question 2: Certain provider systems in Massachusetts are reimbursed significantly more than others for the same services even though there are virtually no differences in quality. Does the state have a part to play in addressing these disparities?

“We need a lot more transparency about what these prices are set at, and more accountability for the systems that are charging significantly more. Then it has to be well-known to the public and payers. Purchasers of care need to be alert to that and help patients stay alert to it.”

Question 3: More than a dozen state agencies have a role in health care. Is there an opportunity to consolidate or rationalize them?

“One of my main goals [at CMS] was to rationalize the many, many different silos or compartments within the agency. Sometimes that has to be done structurally.”

“I’m in favor of extremely high levels of cooperation with agencies and if they don’t cooperate, then we have to consider restructuring.”

Question 4: Government policy has encouraged adoption of electronic medical records. However many providers complain about the systems and the benefits have been slow to materialize. Should state government play a role in helping to realize the promise of health information technology?

“Electronic records can play a big role in helping physicians and nurses. They also can be available to the patients. So it’s a very important step.”

“Federal leadership on information exchange and interfaces… has been very slow.”

“The new wave of so-called Meaningful Use requirements… will help places move more swiftly toward interface compatibility.”

“I’m encouraging relevant state agencies to get on board, and the providers of care to really adopt these new standards as fast as they possibly can.”

Question 5: Hepatitis C is 3 or 4 times more common than HIV. New drugs that can cure the infection are coming on the market this year but they are very expensive. What role should the state play in ensuring that residents are tested, linked to care, and have access to these new medications?

“I abhor the concept of rationing.  I think there’s no way we should be withholding any effective treatments from patients.”

“Once we have in our hands technology that works, and is proven to work, we have to make sure it’s accessible to everybody.”

“We have to recover money from ineffective care, wasteful care, and harmful care.  We need to work very hard to make sure that we have the resources liberated from health care waste, so we can rededicate them to things like proper Hepatitis C care.”

Question 6:  There are multiple health care related ballot questions. What are your thoughts about them? 

“I don’t think it’s a good idea to legislate ratios. I think what we should legislate is adequate care.  I favor standards in the Commonwealth in which we absolutely guarantee that all patients have adequate nurse coverage at all times.”

“To put a specific ratio into legislation could be a mistake. It’s trying to do management with law and I think that’s a mistake and I fear that a ratio in law that’s intended to be an adequate number will soon become a ceiling.”

Question 7: What did you learn from running CMS that will be useful as Governor?

“I loved running CMS. It’s the largest agency by budget in the federal government, $800 billion.  It’s 5,500 employees.”

“I know a lot about executive leadership for improvement in quality and excellence.”

“I set very high goals. I invited everybody to join as a single team.”

“[At CMS] I encouraged them to innovate in their jobs. So the workforce had the support from me to try new things. Even if they failed, we still learned. I emphasized customer focus.”

“We will work very hard on excellence and quality in operations of the state government, from top to bottom, end-to-end, and I will personally invest in that as I did in leading CMS.  What I learned there is that it works in government just as it does in the private sector, if you’ve got a leader that understands that.”

Question 8:  Much of the emphasis in health care reform is on adult patients. Is there a need for a specific focus on children’s health?

“The well-being of children poses a very exciting challenge, and one that the state ought to be embracing, which is to understand child well-being as a totality.”

“If you want to have a healthy child, you have to think systemically.”

“A healthy child isn’t just getting good healthcare. They also need a healthy environment. They need parents who have a secure role in the economy. They’re not being challenged by unsafe streets, or threats in the air, in the environment, or from pollution.”

“I’d love to foster a community-by-community endeavor in the entire Commonwealth on a voluntary basis. That’s involving every community to improve the well-being of every young child, in cooperation with families, and really assure a child’s readiness for school, good nutrition, and high self-esteem. I think we can do that in the Commonwealth.” 

Question 9: Is there anything you’d like to add?

“I want to emphasize how excited I am about the possibility of bringing my skills in executive leadership and improvement into the leadership role of Governor.  I’ve worked in large systems and I understand how to recruit energies of the workforce on behalf of the people who are served.”

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By healthcare business consultant David E. Williams, president of the Health Business Group.

National Family History Day

Chip off the old blocks

Chips off the old blocks

You could be forgiven for thinking that today is Thanksgiving or Hanukkah or even Thanksgivukkah! Actually, it’s National Family History Day, a chance to speak with your close relatives about their health histories. Having a clear family medical history can be useful if your primary care doctor is the thorough type who asks about these things and takes them into account for prevention, diagnosis and treatment.

The Surgeon General offers My Family Health Portrait for those who want to create an organized family history.

You may want to wait till after the feast to initiate this discussion, lest it lead to familial friction by giving everyone an extra reason to critique eating habits and health behaviors.

photo credit: Stéfan via photopin cc
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By David E. Williams of the Health Business Group.

Arizona takes a sane and logical path on Medicaid expansion

The fact that so many states are opposing the expansion of Medicaid that comes with Obamacare is a sign of the crazy political world in which we live, where many conservative Republicans automatically oppose whatever President Obama favors. After the Supreme Court upheld Obamacare but limited the ability of the government to impose the expansion of Medicaid, some Governors, such as Texas’s Rick Perry and Louisiana’s Bobby Jindal have taken a hard line against accepting more people into the program, even though the federal government pays virtually the entire cost.

Rejecting Medicaid expansion will cost the states dearly. The only way this is a rational strategy is if it helps to undermine Obamacare and thereby lead to its ultimate demise. This does appear to be what Perry and his brethren are attempting.

Arizona Governor Jan Brewer has taken the more rational approach. She realizes that the Medicaid expansion is the key to making the budget math work in her state. She’s so convinced that she’s put a heavy squeeze on her fellow Republicans in the legislature who prefer the Perry path. Lo and behold she’s come away a victor and Arizona will move forward with Medicaid expansion.

Obamacare will hit some bumps –thanks in large part to foes obstructing its implementation — but will ultimately prevail. In the end Perry, Jinal et al. won’t look good and will have done lasting damage to their states. The Jan Brewers of the world will look much better in retrospect.

Rerun: Why does some “pure” vanilla contain corn syrup or sugar?

The Health Business Blog is on vacation this week. Here’s a rerun of a post that originally appeared a year ago.

Last month I noticed that the store brand “pure” vanilla extract I had just purchased contained corn syrup, whereas the brand name version in my pantry didn’t. From the pharmaceutical industry I’m used to generic products being essentially identical to branded items, and I guess I just assumed the same was true with foods. Turns out that’s not the case, at least with vanilla.

I sent the following email to SuperValu, whose name was on the Shaw’s brand product, on December 18:

“In the past I have purchased McCormick Pure Vanilla Extract. This time I purchased Shaw’s Pure Vanilla Extract. When I compared the labels I was disappointed to see that while both products contain vanilla bean extractives in water and alcohol, the Shaw’s product also contains corn syrup.

How much corn syrup is in there and why?

It seems to me that it is misleading to refer to the product as pure and then include corn syrup. What do you think?”

I received a response within two hours. SuperValu didn’t know the answer but promised to check with the supplier to find out the answer within about five days. I was just starting to think they’d forgotten about me when I received the following email today:

“Dear Mr. Williams:

Thank you for taking the time to contact us. We welcome the opportunity to address your disappointing experience with our Shaw’s Pure Vanilla Extract.

Pure Vanilla has a standard of identity provided by the Federal Government. This means the formula must contain certain ingredients which are standard to that particular product.

The word pure indicates the vanilla flavor comes only from the extractives of the vanilla bean. The amber colored liquid known as pure vanilla must also contain, at least, 35% ethyl alcohol and is the extractives of 13.35 ounces of vanilla beans. Other optional  ingredients that may be added to pure vanilla are sugar or corn syrup which enhances the delicate vanilla flavor.

If you wish to respond to this note by e-mail, please include your name and e-mail address.

We hope to have the continued pleasure of serving you.

Sincerely,

[Name of  Person]
Consumer Affairs Specialist”

Interestingly, the email was from McCormick Consumer Affairs, which I assume means McCormick makes both the branded and store brand versions on sale at Shaw’s. That’s a different story from what I see on store brand OTC medicines, which often contain explicit labels indicating they are not made by the branded producer.

This Yahoo Answers page indicates that corn syrup is used to mask inferior beans, which sounds like a logical explanation. Even if the beans are the same quality it’s probably cheaper to include some corn syrup.

In any case, it’s back to the pricier brand name version for me next time. And I still think it’s misleading to call this product “pure” even if the government allows it.

 

Health insurance unaffordable for smokers? Here’s another way to look at it

Smoking penalty: Individual health care coverage could become unaffordable for many people is the headline of an Associated Press editorial masquerading as a news story. The gist of the piece is that older smokers won’t be able to afford health insurance because health plans will be allowed to charge smokers up to 50 percent more than what non-smokers pay. The article strongly implies that the law is unfair to smokers and should be changed.

But rather than frame the piece as smokers not being able to afford health insurance, maybe AP should have described it as people not being able to afford to keep smoking. According to the CDC, about 70 percent of smokers want to quit, so perhaps the added financial inducement will succeed where other smoking cessation approaches have failed.

Smokers really do cost health plans more so it’s not as though the rule is without merit. And imagine how happy an ex-smoker will be when s/he saves thousands on health insurance and thousands more by not paying for cigarettes.

In case you wonder why I criticized the article for being a masked editorial, here’s the lead paragraph:

Millions of smokers could be priced out of health insurance because of tobacco penalties in President Barack Obama’s health care law, according to experts who are just now teasing out the potential impact of a little-noted provision in the massive legislation.

Here’s what’s wrong just with that sentence:

  • It’s not President Obama’s health care law. It was passed by both Houses of Congress and signed by Obama.
  • Who says experts are “just now teasing out the impact” or that the provision is “little-noted”? This provision is pretty clear and wasn’t hidden.
  • And what’s the point of calling the legislation “massive”? It doesn’t contribute anything to the story

Waking up? GOP Governors want to talk to Obama about health reform

Republican Governors had been busy talking at –rather than with– the Administration about the Affordable Care Act. Now that President Obama has won re-election their tune is changing at least somewhat. Eleven Governors sent a letter asking to meet with the President to discuss the ACA and in particular to make their case that there should be more flexibility in how the law is rolled out. Signatories include Florida’s Rick Scott and Arizona’s Jan Brewer, both of whom have publicly insulted the President in the past.

No doubt there is some merit to the idea that states should have some flexibility in how they undertake health reform. On the other hand, by opposing the passage and implementation of Obamacare so vigorously –including suing the Feds, refusing to set up state health insurance exchanges, and opposing Medicaid expansion– these Governors have really been picking a fight.

Maybe the Governors should start their meeting with the President with an apology, because at this point the President is justified in shoving Obamacare down their throats.

Doximity: Professional network for physicians (transcript)

This is the transcript of my recent podcast interview with Doximity CEO Jeff Tangney.

Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Jeff Tangney.  He is co-founder and CEO of Doximity.  Jeff, thanks for being with me today.

Tangney:            Thanks David.  Great to be here.

Williams:            Jeff, with so many existing social networks out there, why would you start a new one?

Tangney:            Good question.  All of us feel we’re getting all these notifications and updates and requests, but as a physician, there’s actually no good way to communicate with other physicians.

Email is illegal because it’s not HIPAA compliant. Neither is texting.  Today, if a physician wants to get –for example– a lab value on a patient that they saw last week, most of it happens over the fax machine.  In fact, 15 billion faxes were sent in health care last year in the United States.

We’re making that whole process a little easier, a little bit more like the teenager sitting in the patient waiting room on Facebook or Twitter and a little less like the 1970s.

Williams:            It’s amazing –the fax machine.  It’s the seventh birthday of the Health Business Blog; seven years ago in one of my first posts I wrote about my disbelief that fax machines were still around.  And they’re still with us today.  Maybe in another seven years they’ll slow down a bit.

Tangney:            They’re going strong.  Our goal is to rip it out of the wall.

Williams:            You mentioned similar functionality to Facebook or other mainstream social networks.  How does the functionality of Doximity compare to LinkedIn or Twitter or Facebook?

Tangney:            Reid Hoffman from LinkedIn has a good quote which is that today’s online social networks are really just representations of the offline networks that we’ve had for lifetimes. Facebook is the backyard barbeque, LinkedIn is the corporate office; who’s getting promoted, who isn’t, and Twitter is the bar; people talking about the latest news.

We’re bringing in the hospital; the place where you can have those HIPAA compliant discussions.  We offer authentication of every user.  You not only tell us you’re a doctor, you have to prove that you are.  That allows folks to have HIPAA compliant discussions about patients.

We work on the iPhone, the Android and the web.  About three-quarters of our use is actually on mobile devices because doctors are more mobile than your typical professional.  They can take a photo of a tough case on their iPhone and post that.   We offer iRounds, a curbside consult forum organized by specialty.  That’s not something you would find in your typical forum.

We also do a lot in pre-loading. We pre-populate the CVs of all of our doctors.  We know what articles they’ve published, what clinical trials they’ve done, what insurance they accept, their office phone and fax from a number of public databases. So that even if someone is not yet a member of the network  (and today we have about 8% of U.S. physicians as active members) another doctor can still look them up and find their basic office, phone, fax and clinical history.

Williams:            Do you integrate with other social networks like for example Twitter?  Some of the things I tweet might still be relevant within Doximity.  Is there a way to bring tweets over the wall or is that not part of what you do?

Tangney:            David, I’m guessing you’ve used the product.  Yes, actually that’s one of the popular features.  Doctors who are on Twitter can actually tweet and add a #dox.  You’ll see it in a lot of places these days and that will automatically bring it into their Doximity stream.

Also we integrate with LinkedIn and Facebook.  A lot of people pull over their profile.

Our goal is to provide a place that is safe to talk about patient issues.  It is recreating that offline doctor’s lounge in some ways.  Integrating with these other networks we view as positive.

Williams:            There are some physician-only platforms already.  Sermo is one example. Your prior employer, Epocrates is another platform.  Is there a relationship between Doximity and those?

Tangney:            Sermo is a physician only network, but all the physicians who participate in it are anonymous so that they have a “handle,” nightdoc2 for example.  The discussions tend towards politics.  It’s an interesting social case study.  When you let people wear masks, they have a different discussion than if they’re there as their real person.  There’s a place for Sermo, but we’re offering something quite a bit different.  When you have a real name authenticated network, people discuss different things.

I was one of the two founders of Epocrates and was president and COO for about ten years.  I have a long history and great knowledge of Epocrates.  I left there about two years ago.  We do partner with Epocrates on some things.  Epocrates really isn’t a physician network.  It’s a clinical reference that’s used on iPhones.  We’re evaluating other partnership opportunities that are down the road.

Williams:            One topic that people are always interested in as it relates to social networks is the business model.  What kind of a business model do you have today and what are you expectations about its evolution?

Tangney:            Today we make money from market research firms; Gerson Lehrman Group, Coleman Research Group.  Such firms paid over $100 million last year to physicians in the U.S. in honoraria, typically to talk with someone who needs their expertise.  It’s a hedge fund manager who wants to know what you think of this new stent that just got approved or it’s a medical malpractice lawyer who wants your quick opinion on who the top experts in this area might be.

We require that they pay our doctors a minimum of $250 per hour. In most cases it’s been around $500 per hour. We provide them a LinkedIn for doctors, a place where they can find who really is the expert on specific subjects  –for example neuroendocrine tumors because they have a reporter who wants to talk about Steve Jobs’ disease.  We charge the market research firm a matchmaking fee of $200 per doctor. It’s been a decent revenue source for us and for our member physicians.

Down the road this certainly will evolve.  There are a lot of other directions that we can go.  We have some hospitals, some alumni associations who are partnering with us and paying us to host their medical networks.

As we learned at Epocrates there are a lot of different players who are interested in a physician audience.  Physicians make billions of dollars of decisions every year. Our goal here is like we did at Epocrates, to walk that line, not to make it crass advertising but to offer platforms for folks to communicate about the newest treatments, the newest CME and those types of things.

Williams:            You mentioned that you have about 8% of U.S. doctors on your platform.  Say a little bit more about that in terms of what the typical user profile is and also how you measure utilization.  What are the metrics that are relevant here and what are you achieving?

Tangney:            We are 8% today.  We’re adding about 1,000 new doctors a week right now so we’re continuing to grow at an accelerating pace.

Our average physicians have profiles that are 57% complete.  That means that they have filled out more than half of the fields that we have on our profiles; education including undergrad and medical school, residency and fellowship, work history, clinical interests, faculty, photos, titles, the insurance they accept, and ACOs or medical groups they’re part of or affiliated with or hospitals they’re affiliated with.  Those are the various things that are all very searchable.  Our average user fills in slightly more than half of those.

Our utilization is something that we look at very closely.  We have utilization that is several times LinkedIn. We have about three times as many U.S. doctors on Doximity as are currently on LinkedIn.  Our utilization s well above 10% per week that are coming back and using us to send a message to another doctor or read a news post on iRounds.

As we grow the network, we see that people are finding more people that they know and are more and more likely to use it.  That engagement stat we measure on a weekly basis and it’s continuing to grow.

Williams:            Can you provide an example of a doctor using Doximity to achieve something for a patient that would not have been possible without Doximity?

Tangney:            We’ve got a bunch of examples.  We’ve had a least a dozen major cases solved on iRounds.  One example is a pediatric gastroenterologist in Texas who is the expert in Texas on treating pediatric gastric disorders. He had a patient who he just couldn’t figure out and he posted about the patient in a moment of distress; “Does anyone know what to do?”  He got a reply from a doctor in California who was just finishing a clinical trial on a new type of treatment that has been recently published.  Through that dialogue he was able to find a new course of treatment for his patient and solve her problem.

We had an ER doc, a surgeon who posted about a patient he had seen who had accidentally swallowed a metal bristle from a grill brush.  It had mistakenly gotten into his hamburger and it perforated his intestine.  He posted it as what he called a fascinoma; an interesting and rare case.  He actually found two other emergency room physicians who had encountered the same thing in the last year and so now they’re asking, ah ha, I wonder how common this is.  They are writing a paper on safety standards around grill brushes because if grill brushes are a problem and will perforate bowels across the U.S. they thought that they should bring that to people’s attention.

Williams:            My image of somebody who would be on a service like Doximity is somebody younger, maybe right out of residency.  Is that accurate or what are you seeing in terms of diversity of profiles and users?

Tangney:            Our average age is 40, but it’s a bimodal distribution.  In other words there are some of the young doctors –fewer residents but more fellows.  These are folks who have just finished ten years of training and are hanging out their shingles now, for example as a thoracic surgeon. They are super connectors.  They are the ones who have the greatest business need to stay connected to primary care physicians and referral sources in their areas.  They have the greatest number of colleagues on the network.  They have the greatest amount of activity.

Then we see another bump in the late 50s where you see physicians who realize they’re falling a little out of touch or that they have more time to reengage with some of this technology.  They’re great.  They’re some of the best responders to these types of questions because they have decades of experience and they’re in a place where they have some time now to give back, to mentor, to help folks who haven’t had as much experience.

You’re right that the busy years in the middle, those 40s, they’re our later adopters.  The users are mainly younger docs.  Then we have little blip again in the late 50s and 60s.

Williams:            Doximity strikes me as tool that would be very useful for an independent physician.  How does it fit in with some of the trends toward provider integration?  I’m thinking about phenomena like patient centered medical homes or accountable care organizations.  Would you see yourself having corporate customers or people that are using it as more of an enterprise product?

Tangney:            Yes.  You’re right that private practice physicians see us as having value as a referral network tool, absolutely.  We have 600 doctors from Kaiser Permanente who are in our network, which is more than I ever expected to get.  When you boil it down, even though they’re inside Kaiser and don’t worry about referrals very much and it’s a completely closed system, they still need to collaborate. The tools that they have today don’t have secure texting –and we do.

They don’t have a quick way of pulling up their colleagues’ training just to see for example who wrote the paper on laparoscopic hysterectomies.  We provide them an easy way of doing that and that’s an additional social layer over a lot of the EHR and other systems that they’re currently using.

Williams:            I’ve been speaking today with Jeff Tangney.  He is co-founder and CEO of Doximity.  Jeff, thank you very much for your time.

Tangney:            Great, thanks David.

Rerun: What’s the difference between Colgate Total Gum Defense toothpaste and regular Total?

The Health Business Blog is taking a break this week and rerunning some favorite posts. If you want to comment, please do so on the original post.

I was in the pharmacy recently and saw that Colgate has added a Total Gum Defense line extension to its already large set of Total products. But this product makes exactly the same set of claims as the regular Total –”Helps prevent: Cavities, Gingivitis, Plaque. Fights Tartar, Freshens Breath, Whitens” –and lists the same active and inactive ingredients. Then yesterday I was at the dentist’s office, where there was a big basket of Total Gum Defense samples. I asked a periodontist there if there was any difference and she said, “Not as far as I know.”

I poked around the Colgate website and couldn’t find any differences mentioned there. (Could be hiding somewhere but it wasn’t apparent.) I did find it instructive that the site lacks the ability to compare the various Total products head-to-head, probably because the main differences are how they’re positioned to the market rather than anything substantive.

Finally I called Colgate customer service to ask my question. Judging from how quickly they came up with an answer, this is clearly a question they’ve been receiving a lot. The rep pointed to two differences:

  • The formulation is milder –using a different type of hydrated silica
  • The flavor is less minty –presumably making it more tolerable for those with sensitive gums

I guess it’s enough of a difference to be plausible, and maybe labeling regulations prevent them from being more explicit. But my guess is that Colgate Total Gum Defense is just a typical consumer product line extension, designed to grab a little more shelf space, appeal to a few more consumers, maintain price premiums, and keep generics at bay.