The “words matter” edition of the Health Wonk Review blog carnival is up at Workers Comp Insider. Check out some of the first wonky posts of the year.
It’s always struck me as odd that the dental and medical systems are so separate. Oral health and overall health are closely interlinked, and the mouth is just as much a part of the body as anything else. A commentary in Health Affairs (The Dental-Medical Divide) by Elizabeth A. Mertz, a dental professor at UCSF does a good job of laying out the current state and what to expect going forward. While I learned from the article and agree with many of the conclusions, I do think it’s important that dentistry continue to deviate in some ways from the path followed by the medical profession.
Dentists started as barber/surgeons, and when medical education was organized in the 19th century, dentistry was left out. As dentists started to organize themselves, they naturally built up their own, strong organizations that served their interests and perpetuated the status quo. There was no particular pressure (or even opportunity) to integrate with the medical realm, so the separation has persisted.
On the insurance side, there are also some fundamental differences between the medical and dental fields. In medicine, traditional models of insurance make more sense, because there is a need to insure against very high cost, relatively rare events. In dentistry, most of the costs are for routine, preventive care that should not be financially ruinous. Almost everyone has caries (decay/cavities) and about half of adults have periodontal disease, so there’s not a huge pool of healthy people. And at the time Medicare came into existence, it was typical to lose one’s teeth before old age rolled around, so there was less urgency for dental coverage.
Mertz proposes and predicts a number of changes in dentistry that will bring it more into line with the medical profession and which she expects will address some of the current problems. These problems include wide disparities in care and health status, uneven (and unmeasurable) quality, high costs, and lack of accountability. These are all good things to go after, and there is a lot to learn from the transformation to evidence based medicine, coordinated care, and new payment models.
But wait a minute. In the un-reformed world I am a lot more satisfied with my dental practice (Dr. Daniel Whiteman in Brookline, MA –highly recommended) than my physician offices. So before we push dentists all the way down the doctor path let’s consider some of the shortcomings of healthcare delivery system restructuring and try to learn from them in dentistry. I’m thinking of problems like:
- Too many top-down mandates, like meaningful use –that help achieve uniformity but stifle flexibility and innovation while being costly to implement
- Consolidation of practices and vertical integration with hospitals –which can hurt service and drive up costs
- Reduction in autonomy and introduction of inappropriate incentives, which can take the joy out of practice
Here are my hopes for what reform of the dental profession will achieve:
- Preservation of the viability of the solo practice model. I don’t want to go to an office with a bunch of providers and administrators who don’t know me
- Keeping dentistry patient focused. I feel like a respected customer –as well as a patient—when I go to the dentist. Partly it’s because I’m responsible for much of the bill, and also because I have free choice of where I get my care
- A new model of insurance that pays for the big ticket items while providing negotiated discounts for routine care; care that I will pay for myself
- Encouragement of innovative approaches and technologies that improve outcomes, cost and convenience. UltraTooth –which I plan to cover soon– is one such example
- Greater involvement in oversight by people who are knowledgeable but committed to progress, rather than the status quo. For example, the professional societies appear to be slowing the acceptance of LANAP, a laser-based alternative to traditional periodontal surgery
What are you hoping for in dentistry? Leave a comment, reply on Twitter @HealthBizBlog or send me a note.
Wayne Lipton runs Concierge Choice Physicians, which converts traditional physician offices to “hybrid”concierge practices that provide new options for patients and increase physician income. While we typically hear about concierge practices in primary care, the model is expanding to other specialties.
In this podcast interview, Wayne and I discuss the hybrid concierge model for cardiology:
- (0:11) What is a typical cardiologist’s practice like these days and how has it changed?
- (1:01) How have the practice changes worked out for physicians and patients?
- (1:48) Do patients with cardiac issues use their cardiologist as primary care physicians or do they still maintain primary care relationships?
- (3:06) Within primary care we’ve seen a shift toward concierge models. Why haven’t we seen that in the specialties?
- (4:22) What is a hybrid model like? Does a physicians have to remember when they are acting as a concierge versus the traditional hamster wheel model?
- (6:15) Are a lot of the cardiology concierge patients also concierge primary care patients?
- (8:26) How does a concierge cardiology practice differ from a concierge primary care practices? How do the economics compare?
- (11:08) What do health plans think of concierge medicine? What is the impact on new models of reimbursement?
- (13:37) Would a practice that added on a hybrid model be more or less attractive to an ACO? Would the practices want to participate?
- (15:50) How broad is the opportunity to add this model in cardiology? Are other specialties also ripe?
- (18:29) How do you implement?
- (21:35) How does your company get paid?
The best defense is a good offense. I assume that’s what Partners HealthCare CEO David Torchiana had in mind when he penned First do no harm in the Boston Globe. In a nutshell, he argues that healthcare costs in Massachusetts are more affordable for businesses and individuals than elsewhere in the country, that they are becoming relatively more affordable, and that the state should resist the urge to impose further cost controls.
I’ve made similar arguments about affordability myself. See for example, Massachusetts: Land of affordable health insurance from back in 2011.
While Massachusetts has retained its affordability relative to other states, healthcare is taking up a higher and higher percentage of families’ incomes, including in Massachusetts. Medicaid and other healthcare spending dominates the state government’s spending growth, squeezes out discretionary initiatives for priorities such as education, and necessitates the tough budget cuts Governor Charlie Baker is making.
I’m sure I’m not the only one whose eyebrows were raised by Torchiana’s sanguine perspective.
Partners also should not claim too much credit for the reasonableness of healthcare spending in Massachusetts, considering that its own costs are among the highest. Despite receiving substantially higher reimbursement from commercial payers than other providers and enjoying a richer payer mix, Partners recently reported a record loss of $108 million for the year. Meanwhile, its smaller rivals –including those who treat a higher proportion of Medicaid patients and receive lower commercial reimbursement rates– are reporting better financial results.
If Partners had remained just Massachusetts General Hospital and the Brigham & Women’s Hospital I don’t think its executives and lobbyists would have to expend so much effort fending off the state. Massachusetts residents are justifiably proud of the worldwide reputations of these hospitals, which draw tremendous research dollars from the NIH and elsewhere, attract patients from around the world, and are equipped with the medical expertise and equipment to treat the most complex conditions.
No, the issue is that over the years Partners has dramatically expanded its footprint throughout the region, buying up or partnering with community hospitals and physician practices, and expanding its own overheads as it grapples with the balance between central and devolved management. Partners is now in the business of providing routine care throughout the region, and that helps drive up costs and puts the company in the spotlight. As the state grapples with bringing costs in line with benchmarks, Partners cannot expect to be given a free pass.
So there are a couple of alternatives: #1: Partners can bring its own costs closer in line with rivals or #2 it can divest its community assets and focus on being a great academic medical center. From what I can see, Partners is pursuing a light version of #1 while simultaneously slowing its plans to further expand in the community and mounting a charm and lobbying offensive with the state and the public.
Many drugs fail in development due to safety problems. A study indicates that impurities in the non-active ingredients may sometimes be to blame. According to lead researcher Daniel Weinbuch from Leiden University:
“We found that sugar excipients themselves contain nanometer-sized particles, which can damage proteins and make drugs unsafe. These nanoparticle impurities in sugar could even trigger the immune system itself.”
Obviously, drug companies need to learn about this problem and find sugar manufacturers who can make pure products.
It’s unfortunate that this problem exists, but it also holds out the possibility that some drugs that were previously thought to be unsafe could actually be safe. If so, it would be time to restart the development process.
The academic paper (Nanoparticle Impurities in Pharmaceutical-Grade Sugars and their Interference with Light Scattering-Based Analysis of Protein Formulations) was published in Pharmaceutical Research.
Trump considers naming FDA chief who would radically overhaul the agency, blares the headline from STAT. The candidate, Jim O’Neill is indeed a radical: he wants to eliminate the requirement for drugs to demonstrate efficacy in order to gain approval, favors payments for organ donors, and is part of a group that wants to create sea-based libertarian communities. He also doesn’t seem to know much about the FDA and its people –he said “one thing that surprised me is that the actual human beings at the Food and Drug Administration like science; they like curing disease and they actually like approving drugs and devices and biologics.”
As scary as the guy sounds, in practice he probably would not have much of an impact. Here’s why:
- Just because a drug or device is FDA approved does not mean payers will pay for it. Pharma and device companies have to demonstrate that their products work and that they are cost effective before they will be reimbursed
- Since the biggest payers are Medicare and Medicaid, even if you take FDA out of the business of judging efficacy the government is still heavily involved. (However, some Republicans including the likely HHS Secretary look favorably on eliminating Medicare and Medicaid, which I guess would negate my point)
- O’Neill still thinks products should be shown to be safe before they gain approval, and that’s arguably more important than efficacy in terms of saving lives. But safety can’t be fully evaluated without considering efficacy. A really effective drug that’s active against a serious illness can be considered “safe” even if there are occasionally serious side effects and even deaths. But we wouldn’t accept the same safety profile as “safe” for more benign conditions
- O’Neill says FDA is under too much pressure from Congress in its current structure. Whenever there is an unpopular decision the commissioner has to testify before Congress, where he’s raked over the coals. I think the same thing will still happen –the public will rise up, perhaps even more, if FDA backs off its traditional role
Ted Cruz actually had an even more radical approach.
So, rest easy for now.
Kindly Care got its start by helping families hire, onboard, manage and compensate caregivers. Now it is expanding its offering with Care Exchange, which allows home care agencies to collaborate.
I interviewed CEO Igor Lebovic to find out more.
- (0:10) What is the problem you are addressing with Kindly Care?
- (0:37) How did you decide to pursue this market?
- (2:32) You say you meet the caregivers. How do you meet them?
- (3:58) How much overlap is there between what you do and what Nanny Tax companies do?
- (4:58) You just launched Care Exchange. What is it?
- (6:10) I’m confused. Are you disintermediating agencies or are you working with them?
- (8:52) Care.com and Honor sound like they are doing something similar. How are you different?
- (10:28) How are you funded? What are your hopes and aspirations?