Category Archives: International

Looking abroad for healthcare answers

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Serious students of the US healthcare system understand that costs are high and quality is uneven. While there are some incredible components of our system, it’s clear to me that we should look elsewhere for best practices that we could apply in the US. That outlook led to my interest in “medical tourism,” which I spent some time focusing on just before the Obamacare era.

A Harvard Magazine article (Global Health at Home) starts with the same premise, and cites a statement from the World Bank president that “situations of scarcity lead to innovation.” This gets right to the heart of the matter, because in the US high and rising costs are taken for granted, and budgets are not really a constraint. As a result we are not forced to think differently and creatively.

I was a bit surprised that the authors then jump to the conclusion that the solution is global health, which is “premised on taking responsibility for all people in a given location.. and at all levels of income. Philosophically, global health is guided by the words of… Paul Farmer, co-founder of Partners in Health: ‘The idea that some lives matter less is the root of all that is wrong with the world.’ Equity is the soul of global health.”

The authors use the term “Global Health at Home,” to describe their concept of bringing this global health approach, developed for poor countries, back to the US. Their solutions are pretty sensible: a holistic approach to chronic diseases, attention to identifying and addressing the social determinants of health, deployment of community workers, and an emphasis on care at home. These are good ideas but we don’t have to go abroad to learn them and frankly I don’t see that equity is the key lever for cost containment in the US or elsewhere.

I’m thinking about how scarcity has led to innovation in other fields: like how farmers in Israel innovated in irrigation to compensate for the lack of water or how earlier computer programmers developed elegant programming approaches when memory was a scarce resource (unlike the typical bloatware we see today).

What are the equivalent opportunities in healthcare, from both a process and product standpoint? What clever and efficient approaches are being taken for diagnosis and treatment in resource constrained settings? Can we apply them to the US? If we do, are there trade-offs that we need to consider?

What barriers are in place and can or should they be lowered? These may include regulatory requirements, malpractice risks, and payment methodologies.

It’s a topic worthy of systematic inquiry. I assume people are working on it, so if you’re aware please let me know on Twitter @HealthBizBlog

As a sidenote, it’s inspiring that the lead author of the Harvard article is in his 90s and still going strong!

Image courtesy of KROMKRATHOG at FreeDigitalPhotos.net

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

The case for healthcare cooperation with Cuba

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I learned quite a bit from a brief Perspective in the New England Journal of Medicine (The United States and Cuba –Turning Enemies into Partners for Health).

A June Memorandum of Understanding (MoU) between the US Department of Health and Human Services and the Cuban Ministry of Public Health lays out a wide variety of areas for cooperation, including infection diseases like Zika, plus cancer and chronic conditions.

Thanks to the embargo, products developed in Cuba aren’t available in the US because they are not allowed into the FDA approval process. As a result, certain drugs like Heberprot-P, to reduce amputation risk for diabetic foot ulcers, aren’t available in the US even though they are on the market in many other countries.

We don’t need to copy the Cuban health system, but there are some lessons to be learned from Cuba’s experience with population health, community-based programs, disease control, and chronic care management.

It isn’t possible to fully implement the MoU now, because the embargo remains in place and only Congress can lift it. If Democrats take control of Congress, that could happen soon. If not, the author argues that the President has the authority to allow Cuban products into the US regulatory process just like products from any other country. He’d also like to see the President allow US students to attend medical school in Cuba, where some have been offered scholarships.

These all sound like good ideas to me and I hope they are implemented.

Image courtesy of taesmileland at FreeDigitalPhotos.net

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

Canada is looking better and better

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O Canada!

In almost every election cycle people talk about moving to Canada if a presidential candidate they despise takes office. In practice few make the move. Things could be a little different this time around if a certain nationalist strongman comes to power.

There’s something else to fear this year: the Zika virus. According to NIH director Tony Fauci, mosquitoes with Zika are likely to arrive in the US mainland within the next month or two. One species will be all over the South, another will come up the East Coast as far as New England. Already, close to 300 pregnant women in the US are infected.

Congress is dithering with the President’s request for funds to combat Zika’s spread and is toying with the idea of canceling Ebola funds to partially support the Zika fight. It’s pretty irresponsible.

In the past I would have assumed that Congress would get it’s act together and do the right thing. But after seeing some members unconcerned about preventing a default I no longer take good intentions and common sense for granted.

Zika is serious and its spread could have a big impact on economic growth. In El Salvador, the government has advised women not to get pregnant for the next two years, lest they give birth to babies with severe birth defects. Can you imagine the impact such an advisory would have in the US?

Image courtesy of Vlado at FreeDigitalPhotos.net

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

The false link between mental illness and gun violence

It would be nice if we could eliminate mass shootings by improving the mental health system, coaxing (or forcing) potential shooters into treatment before they have a chance to wreak havoc.  As the Washington Post (Most mass shooters aren’t mentally ill. So why push better treatment as the answer?) reports:

“It would be ridiculous to hope that doing something about the mental-health system will stop these mass murders,” said Michael Stone, a forensic psychiatrist at the Columbia College of Physicians and Surgeons and author of “The Anatomy of Evil,” which examines the personalities of brutal killers. “It’s really folly.”

This seems pretty obvious, and yet Republican and Democratic leaders, along with the general public and the media seem to think mental illness is the root cause of shooting sprees and that improving the mental health system can fix the problem.

After mass shootings, reporters often jump quickly to mental illness as the cause. Remember after the Sandy Hook shooting when there was speculation that the shooter’s Asperger’s diagnosis was to blame?

Asperger’s? Are you kidding me?

The danger of our fixation on mental illness as the root cause of violence is that we end up stigmatizing people with mental illness –and developmental disorders– while ignoring more direct causes of gun violence, such as ready access to guns.

Mass shootings are rare outside the US. Is there someone who can tell me with a straight face that the difference is due to better mental health systems abroad?

Meanwhile, Australia has seen a major decrease in gun violence over the past 20 years since adopting strong gun control after a mass murder. That seems like a more evidence and logic based response than what we’ve tried here.

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

 

Listen app: ResApp diagnoses respiratory ailments

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I’m intrigued by an Australian company, ResApp that has developed a smartphone app to diagnose respiratory diseases by analyzing the sound signatures of coughs. The company has just completed an oversubscribed fundraising round, so I guess I’m not the only one who finds it interesting.

I interviewed the CEO, Dr. Tony Keating via email, and his answers are below. Meanwhile, check out the demo for their consumer-facing product.

What is ResApp? from ResApp Health on Vimeo.

Q1. What unmet need does ResApp serve? How big is the need?

ResApp is developing digital health solutions for the diagnosis and management of respiratory disease (e.g. pneumonia, bronchiolitis, asthma, COPD). We estimate that every year more than 700 million doctor visits result in the diagnosis of a respiratory disease within the OECD, in the US the number is 125 million visits. Pneumonia in particular costs the US hospital system $10.5 billion annually. The World Health Organization estimates that nearly 1 million children die of pneumonia in the developing world every year, with a large portion attributed to the lack of availability of a low cost diagnostic tool. 

Current diagnosis of these disease is costly and time consuming (consider that an x-ray for pneumonia diagnosis in the US costs more than $200 and can take up to an hour in an emergency department), and there are also many areas where current diagnostic tools are unavailable. Our initial focus is to provide an accurate remote diagnostic capability to telehealth where even the stethoscope is not available to physicians. 

Q2. How does the system work?

ResApp’s technology is based on the premise that cough and breathing sounds carry vital information on the state of the respiratory tract. We use machine learning algorithms that analyze the sound of a patient’s cough. Our algorithms are able to match signatures that are within a patient’s cough with a disease diagnosis. An analogy might be how speech recognition algorithms match speech to text, or how Shazam’s algorithms look for signatures in music to identify the artist and title. 

Q3. Who came up with the idea? How?

The technology was developed by Dr Udantha Abeyratne and his team at The University of Queensland. Dr Abeyratne and his team have been engaged in the R&D of the technology since 2009. They were initially funded by a grant from The Bill and Melinda Gates Foundation to investigate if mobile phones could be used to diagnose pneumonia in the developing world. The initial idea was to take the latest advances in speech recognition technology and couple them with physicians’ in-depth knowledge of cough and breathing sounds to develop a diagnostic test that could be delivered at low cost to patients in the developing world. 

Q4. You started as a telehealth app but are now looking to serve physicians for in-person visits, such as in the emergency room. Why?

Our focus remains on providing a remote diagnostic test to be used alongside a telehealth consultation. However we have seen great interest from physicians for use in in-person visits, such as in the ER. The potential of our technology to provide an instant and highly accurate differential diagnosis of respiratory disease is seen as a way to greatly improve the diagnosis and treatment of their patients. In addition, healthcare payers could potentially realize significant cost savings versus traditional diagnostic tests (such as chest x-ray). 

Q5. The app doesn’t require any additional hardware. Is a smartphone really good enough to serve as a medical device?

Our clinical study, run out of two major Australian hospitals, has demonstrated very high levels of accuracy (both sensitivity and specificity) in diagnosis from recordings taken using the microphone on the smartphone. We are simply using the smartphone as an efficient platform for delivering a clinical-quality medical diagnostic device. The FDA has approved over 100 mobile medical apps, including a number that diagnose a disease. 

Q6. Your initial focus is on diagnostics. Do you also plan to offer tools for ongoing management? 

Yes, our recent fundraising allows us to accelerate our plans to develop tools for ongoing management of the chronic respiratory diseases asthma and COPD. We see an opportunity to potentially measure the severity of these conditions on a more regular basis than what is done today. We also see the opportunity to deliver these management tools to all smartphone users who suffer from these conditions, without the need to purchase additional hardware (or perhaps also just as importantly, without the need to carry a second device). 

Q7. What geographic markets are you serving? Are you worried you are spreading yourself to thin?

Our focus is the US telehealth market, although our recent funding extends our US market into the in-person use by a physician. In both of these instances, we are still providing the diagnostic result to the physician, not directly to the patient, so our clinical studies and FDA submissions are essentially unchanged. We have recently seen growth in telehealth, in particular in Europe and Australia and will be working through the regulatory process in those regions in parallel to the US regulatory process.

Q8. What’s to prevent someone else from copying what you are doing?

The university has filed a patent application (which ResApp has a worldwide exclusive license to) describing the method and apparatus of respiratory disease diagnosis using sound. The machine learning algorithms that we use also require a significant amount of high quality clinical data, which we have generated from our multiple clinical studies. 

Q9. Anything else to add?

ResApp’s technology, originally developed by a world-class team at one of the world’s leading universities, provides an opportunity to deliver a clinical-quality medical diagnostic test for respiratory disease to everybody who has a smartphone in their pocket. While we’ve talked a lot about the opportunities in the US, Europe and Australia, we must remember that there are also billions of people in the developing world who do not have access to quality healthcare. We have recently partnered with a leading global humanitarian organization to help bring a high accuracy, low cost diagnostic test for pneumonia to those people and to try to reduce the number of children who die from pneumonia and other respiratory diseases every year in the developing world. 

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

How immigrants help health reform succeed

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Medicare turns 50 today, which has provided an opportunity for all manner of retrospectives and speculation about what the future holds. The Partnership for a New American Economy is publicizing one of my favorite arguments: that immigrants are a key reason that Medicare is still solvent.

Their 2014 study (Staying Covered: How Immigrants Have Prolonged the Solvency of One of Medicare’s Key Trust Funds and Subsidized Care for U.S. Seniors) concludes:

  • Immigrants are subsidizing Medicare’s core trust fund
  • Immigrants played a critical role subsidizing Medicare’s Hospital Insurance Trust Fund during the recent recession
  • Medicare’s Hospital Insurance Trust Fund would be nearing insolvency if not for the contributions of immigrants in recent years

Bottom line: immigrants contributed $182 billion more to the Hospital Insurance Trust Fund between 1996 and 2011 than they received in benefits. Meanwhile, US-born citizens sucked out $69 billion more than they paid in.

But the argument for open integration goes far beyond the Medicare story. As I wrote back in 2011 (We need a liberal immigration policy to support health care reform)

  1. Immigrants innovate and create economic growth. This growth is how the country gets wealthier and better able to support health care expenses without raising tax rates
  2. Immigrants can use their intellectual capital and training –whether acquired abroad or here– to fill healthcare jobs such as primary care physician, pharmacist, nurse that would otherwise go unfilled

We have very stupidly made the US less welcoming to immigrants at the same time that talented people have more opportunities in their birth countries and while other countries have made it easier for educated immigrants to thrive. I partly blame the current state of affairs on the post-9/11 mentality. We’ll pay for it in the long run in healthcare and in the economy at large.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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

Partners HealthCare goes global: Is it a good idea?

There's gold in them thar hospitals

There’s gold in them thar hospitals

In shift, Partners HealthCare seeking growth globally in today’s Boston Globe describes how Partners is turning its focus from dominating the Massachusetts healthcare delivery system to looking for revenue growth overseas.

This wasn’t hard to predict, and it makes a good deal of sense. Last year the Globe asked me to speculate on whether Partners’ hiring of a new CEO would change the company’s strategic course. I said it was surprising that Partners had continued its relentless expansion in Massachusetts. While it made sense to affiliate with community hospitals and physician practices to generate complex referrals for “tertiary” care, it was puzzling why Partners wanted to be in the business of offering the most cost-effective colonoscopies and other routine services throughout the state, generating friction with the state government, health plans, employers and consumers as a byproduct.

I suggested that Partners might choose to return to its roots as a world-renowned academic medical center with its Massachusetts General and Brigham and Women’s hospitals. Interestingly, from today’s article it appears that MGH and the Brigham –not Partners itself– are the entities that are driving forward. MGH plans to manage a hospital in China near Macau while the Brigham has recruited a chief business development officer from Johns Hopkins to set up business in the usual hotspots for high-dollar international medical ventures, i.e., China and the Persian Gulf, with a nod toward emerging South American economies.

Using the MGH and Brigham brands is wise, and helps remind us of just what Partners is. Remember, Partners was established to prevent health plans and the state from playing MGH and the Brigham off of one another in contract negotiations. The two hospitals continue to exist –it is not a merger in the traditional sense.

But these entities will have to be careful when they go abroad prospecting for gold. A few things to watch out for:

  • Politics: Picking one foreign partner in a region can mean foregoing the opportunity to work with that entity’s rivals. And if an emir is ousted his successor may shoot down the pet projects of the previous emir and his family. (It has happened!)
  • Brand risk:  When I traveled to Asia a decade ago to research medical tourism, the Harvard name and crest were splashed up all over the place by operators who had little or nothing to do with Harvard. That had something to do with an earlier venture by Partners hospitals to use the Harvard name to drum up business overseas. It worked a little too well.
  • Overconfidence:  Sure we have great hospitals here in Boston. But not everyone running a hospital overseas is an idiot; many understand their own health system and patient populations pretty well. When I visited Singapore hospitals I was struck by the openness of executives in speaking with me, and impressed with their approach to cost-effective, high quality care. The one exception was when I visited a Hopkins outpost there, where the staff were highly bureaucratic and unapproachable.  MGH and the Brigham will need to make sure what they take on is aligned with their true areas of differentiation and not just their self-perceptions.
  • Ethical risk: Let’s be honest. American values differ from those of the Persian Gulf and China. As just one example, anyone in Boston can show up at the emergency department of MGH or the Brigham and be treated, regardless of nationality, race, religion or ability to pay. Will that be the case in hospitals MGH and the Brigham work with overseas? If not, is that ok? What else needs to be considered?

I wish the MGH and Brigham well in their overseas forays, and do think it’s a more fruitful approach than further expansion in Massachusetts. The Globe should have plenty more to write about as the strategies unfold.

Image courtesy of pakorn at FreeDigitalPhotos.net

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