Healthcare NBIC

Top Healthcare Conversations of 2008

Many of the great healthcare thinkers and bloggers wrapped up 2008 with end-of-year considerations of the important developments in their fields, and some looked ahead with predictions for 2009. Here are the January 1, 2009 Health Memes from around the web:

Personal Genomics in 2008: the Year in Review  Genetic Future

From 2008 to 2009  ScienceRoll

Finding Venture Capital In 2009 Will Be Tough  Pharmalot

2009 Stem Cell Trendsetters in Neurology and Psychiatry  Brain Waves

The Future of Pharma  Health Beat

The Year in Bioethics: The Highs and Lows of 2008  Bioethics Forum

2008 in Review: Ethnicity Strikes Back  Dienekes' Anthropology Blog

HIT Predictions for 2009 on iHealthBeat  Health Populi

Best of Nanomedicine in 2008  Nanomedicinecenter.com

2009: Predictions Across the Web  ReadWriteWeb

Social Media Trends 2009, TrendsSpotting  ReadWriteWeb

Top 30 Brain Health and Fitness Articles of 2008  SharpBrains

Top 10 In 2008  Health Affairs Blog

Not Exactly Rocket Science Review of 2008 [Not Exactly Rocket Science]  ScienceBlogs Channel : Life Science

Top Health Search Engines of 2008 [Highlight HEALTH]  The Highlight HEALTH Network

The Year in Biomedicine  Technology Review Feed - Biomedicine Top Stories

Health and Health Care in 2009 -- a Year of Managing Risks and Wild Cards  The Health Care Blog

(See the final week of 2008 on the December 29 archive page.)

Google Health 2018: Best -- and Worst -- Case Scenarios

On the face of it, Google Health released this month in beta is just another personal medical record system similar to a hundred others including Microsoft's HealthVault. But Google has designed a specifically open health record: providers, payers and all kinds of service companies can use the published Application Programmer Interface to link their data to your Google health file.

Since Google is not a healthcare provider, the privacy restrictions of HIPPA, the Health Insurance Portability and Accountability Act of 1996 don't apply. Health IT security guru Fred Trotter describes why this is a good thing, and we went brainstorming to see how open architecture might affect wellness, sex, eldercare, insurance and other health concerns.

Read Google Health 2018: Best Case Scenarios.

Read Google Health 2018: Worst Case Scenarios.

The glass is half-full or half-empty. Add your comments below, and or a different comment perspective, see the thread on these articles at Slashdot.

U.S. Healthcare Spending: Good News/Bad News

"It doesn't matter how much money you have, as long as you have your health," they say. That's why it makes sense that the richest country in the world spends the most on healthcare. According to an article in the journal Health Affairs, the good news is that U.S. healthcare spending growth slowed in 2005 to 6.9% annually. The bad news is that total spending reached $2 trillion per year, 16% of the Gross Domestic Product (GDP), almost $6,700 per person for each of the 300 million Americans.

Following the change in control of the House of Representatives and the Senate in the last election, analysts like Jill Gardiner writing in the New York Sun report renewed interest in national political circles for some kind of national health insurance. Citing recent initiatives from New York's Senator and likely Democratic presidential contender Hillary Clinton and incoming Governor Elliot Spitzer, Massachusetts' former governor and Republican presidential aspirant Mitt Romney, and California's Governor Arnold Schwarzenegger, Gardiner notes that the latest policies bring business needs into the debate: companies' healthcare costs now amount to significant proportions of overhead.

A national plan like Canada's or England's won't do. Gardiner quotes Dr. David Gratzer of the Manhattan Institute who noted that coverage is more available than is regularly assumed. A third of the 46 million Americans who are uninsured are already eligible for government-subsidized insurance but have not signed up; another third earn $50,000 or more. "That seems to be a crisis in signing your name to a piece of paper, rather than a crisis in coverage," Gratzer grumped.

Healthcare spending is likely to become the big domestic policy topic of the 2008 presidential election campaigns. With any luck, we'll get some comprehensive discussion of the issues in the next 22 months.

Walmart's Loss Leaders: First Beyonce, Now Prozac (fluoxetine hydrochloride)

In the new year, Walmart now offers a $4 prescription price on more than 300 generic drugs in all Walmart controlled pharmacies in 49 U.S. states. As we saw in the previous posts Walmart's Tough Choices and  Walmart Medical Clinics, disruption is bound to happen as 21st Century business comes to grips with the 20th Century way we have of handling healthcare.

The pricing power of Walmart and its willingness to discount deeply to get customers into the store has already transformed the music industry. The list price on Beyonce's second solo album B'day is $18.98, but you can get it at Walmart for $11.98. (You can alternately download the album's three good tunes -- including the currently hot $3.49 single Irreplaceable -- for just 88 cents apiece.) Now they're selling the generic form of Prozac for just $4 for a month's supply versus the $33 average  branded price.

In the study Market power in music retailing: the case of Wal-Mart published in the academic journal Popular Music and Society, Mark A. Fox analyzes how Walmart's discounting changed the record business by highlighting only sure-fire bestsellers. More ominously, he describes the content decisions Walmart forces on artists: no cover art or lyrics that are too sexy, no songs denigrating Walmart, and no albums with Parental Advisory stickers.

Walmart's ability to drive down the cost of genercic drugs is a good thing. But in the pharmaceutical context, questions arise: "How does Walmart decide which generics to offer at low cost?" I didn't see a Contraceptive category, for example, although in the Hormones category medroxyprogesterone AC is listed in 2.5, 5 and 10 mg dosages. "What influence does commerce have on medicine?" There are lots of cardiac and diabetes offerings, but only one generic cancer drug and two Parkinsons generics. Chronic patients with repeat business seem to get a better break than short-timers who get cured or die. "How will Walmarts' near-inevitable monopsony power --  its control over suppliers -- influence pharma companies' choices in drug discovery, packaging and dosage. " Walmart prefers Splenda, so Coca-Cola had to change its new product to use Splenda. When it comes to medicine the potential for nutty conspiracy theorists is astounding.

Disgruntled Docs Go Out of Network

Hundreds of pissed off MDs gathered at a seminar in New York recently to find a way to beat the healthcare system, specifically the managed care system that they say underpays, overmanages and cheats both doctors and patients. New York has the highest percentage of doctors per patient in the U.S., 328 per 100,000 versus the national average of 281 per 100,000, and the highest concentration of world class hospitals. It's a good place to be a patient, but apparently a lousy place to run a medical practice.

Doctors, lawyers and consultants shared their views on patient care..

"Out of Network Practice: Opportunities and Benefits," sponsored by the Business Development Institute and Castle Connolly Medical, Ltd., showcased doctors who operate outside of the managed care system. Their patients pay on the spot and later file with their medical insurance carriers for reimbursement -- usually partial reimbursement. Patients get the doctor they want and therapies that are not subject to the care restrictions cooked up the the managed care beancounters; doctors charge what they need to make a living, do without expensive medical billing staff, give more time per visit to a smaller patient roster, and -- to hear them tell it -- get a better quality of life as the healers they always wanted to be.

Mustargen: A Bad Case for a Nasty Old Drug

Every salesman knows that it's a sin to "leave money on the table," to get an order too easily, to take $5 when the buyer would have paid $500. In this world, the price for something is what people are willing to pay for it -- not what it costs to make, not for the good that it may do, not for the harm that it may cause.

Alex Berenson's March 12 New York Times article "A Cancer Drug's Big Price Rise is Cause for Concern" describes a standard Big Pharma free market horror story: Joyce Elkins of Georgetown, Texas saw her $77.50 cancer medication Mustargen jump to $548.01 within two weeks. Merck, the drug's original manufacturer, sold the rights to Ovation Pharmaceuticals which promptly raised the wholesale price "roughly tenfold." The gist is that Big Pharma is screwing the most desperate sufferers of cutaneous lymphoma, and something must be done.

But it's a bad case for discussing policy for a lot of reasons:

The Coming Shortage of Dead People

Demography is destiny, and the destiny of the developed world is to have more old people. The two charts above (click to enlarge) from the U.S. Census Bureau report 65+ in the United States [PDF] show two snapshots of the U.S. population in 1940 and 2000. On the left, starting at the bottom, most young people live to adulthood and then start dying off evenly at each age until very few people are left alive at the top of the spear, ages 80 and over.

The last half-century's advances in medicine automation and world peace make the age needle flatten out. As a proportion of the population, twice as many people live past 65 today, and five time as many live past 85. Folks who would have been dead otherwise now live on to spend their children's inheritance, collect social security and demand free drugs from the government.

Slate's William Saletan covered the impact of all this destiny in a weekend article "Bygone Era: Old Age is changing. So should Social Security." His opening line: "The bad news is, we're living longer."  The solution: Work longer (like past 70), curb early retirements, and needs-test Social Security.

(The title of this item comes from last year's Atlantic Monthly article "The Coming Death Shortage" by Charles C. Mann. [$$])

Wal-Mart Medical Clinics

At yesterday's National Governors Association Winter Meeting in Washington, Wal-Mart president Lee Scott (at right) announced the opening of 50 new in-store clinics adding to the handful now run by RediClinic, a division of Interfit Health, a Houston-based firm. Interfit is backed by Revolution Health Group, the post-Time Warner venture of AOL founder Steve Case with a stellar board of tech-savvy directors.

As we wrote in Wal-Mart's Tough Choices last December, the biggest employer in America faces the biggest employee healthcare problem, and Scott says he's dedicating himself to getting state governments focused on realistic solutions -- instead of the employer mandates they've been contemplating. But the most disruptive line from the speech is: “We’re making health care more affordable and accessible to our associates.  And with the clinics, we’re using our business strengths to do the same for our customers and our communities.”

When Wal-Mart starts competing with ol' Doc Welby, things will start changing.

MinuteClinic Retail Care: "You're sick. We're quick."

The sign on the wall at Minneapolis-based MinuteClinic presents the price list for common medical procedures: $49 for a Sinus Infection, $59 for Wart Removal, $39 for a Pregnancy Test. Office hours are 8 to 8 weekdays, 8 to 4 weekends, no appointment necessary. The 90 square foot clinics are located in high traffic retail locations like Target, CVS and CUB Foods stores, usually with free parking. A nurse practitioner backed up by a proprietary evidence-based diagnosis and treatment system gets you in and out in 15 minutes, faxes your primary care physician a report, and accepts most insurance plans. If you have a medical problem not on the list -- about 7% of walk-ins, says MinuteClinic -- you're referred to a primary care physician, urgent care center or emergency room.

Like a JiffyLube, the MinuteClinic does a few things, and does them efficiently and well. The company says that a Sore Throat visit -- including prescription medication -- costs about $62 and 30 minutes versus a primary care physician's $109 and 90 minutes versus an emergency room's $325 and God-know-how-many hours waiting time. Patients are satisfied: 50% are referred by friends, 40% to 45% are regulars, and the firm claims 4 complaints per 10,000 visits. Employers are satisfied: many companies actively promote MinuteClinics and even discount co-pays for employees.

Price transparency. Careful quality measurement. Evidence-based practices. Electronic medical records. 21st Century customer service. You know it's a disruptive innovation when the first item on the agenda for the NAFAC urgent care physicians conference in April is: "Are you threatened by the recent openings of clinics inside big-box retailers or chain drug stores in your community?"

Wal-Mart's Tough Choices: WNYC Tues, Dec 13 | 10am EST

A fascinating internal memo by Wal-Mart EVP M. Susan Chambers (at left) describes the company's healthcare cost crisis and outlines some "limited risk" and some "bold" steps to bring costs under control, make employees happier ... and improve Wal-Mart's public reputation in the face of increasing calls for new state and local regulations. The leaked document, written for the board of directors and based on studies with McKinsey & Company, is brutally honest: older, fatter, sicker, long-employed full-time workers are much more expensive than cheaper, younger, healthier part-time new hires -- but they are no more productive. Wal-Mart's employee benefit costs jumped from $2.8 billion to $4.2 billion in three years. The company earned $10.5 billion on sales of $285 billion last year. (See the recent article by Steven Greenhouse and Michael Barbaro from the New York Times.)

This Tuesday at 10 am EST, Brian Lehrer, host of a talk show on New York's public radio station WNYC, will present "Who Pays for Healthcare?" discussing the memo with an economist and his New York audience (see box below). No doubt, there will be plenty of public radio hand-wringing about the evil corporation where 5% of employees resort to Medicaid, but memo fairly outlines Wal-Mart's relative position in the  overall labor market as well as the stingier retail sect, steps like:

• Health Savings Accounts that reward medical consumerism and build assets year-to-year,
• wellness training programs to stop going to the hospital emergency room and to better use doctor visits and prescriptions,
• discounts for healthier foods,
• in-store clinics like MinuteClinic ,
• adding more physical activity to jobs to force some on-the-job exercise

Some of the memo's notes on workforce productivity and recruiting strategy will scare people who've never run a business, but the healthcare issues for the country's biggest employer are the ones every employer -- and every employee -- will face in the future. There's a lot of disruption on the way, maybe for the better.

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The Brian Lehrer Show: Who Pays for Healthcare?
WNYC New York, Tuesday, December 13, 2005, 10AM on 93.9 FM and AM 820 , rebroadcast at 1AM on AM 820. Available on-line at WNYC.org.
Read the Wal-Mart memo Reviewing and Revising Wal-Mart’s Benefits Strategy: Memorandum to the Board of Directors from Susan Chambers [PDF]

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