Monday, July 17, 2017

The Pennsylvania Gazette » The State of the Health-Care Economy

When David Asch GM'87 WG'89 was executive director of the Leonard Davis Institute of Health Economics, he would occasionally receive phone calls from the institute's founding benefactor.

"Often he started out with a question: 'So David, what percentage of GDP is healthcare these days?'" Asch recalled during an Alumni Weekend panel discussion marking the LDI's 50th anniversary. "And I'd say, 'Well I don't know, Leonard, 15 percent.' At which point he would go ballistic, and say, 'What are you talking about! When I started the Leonard Davis Institute, it was 6 percent! What the heck are you guys doing over there?!'"

At which point Asch would "very carefully" reply: "But had you not started the Leonard Davis Institute, we'd be at 25 percent!"

Asch, who is currently the John Morgan Professor of Medicine and Medical Ethics and Health Policy and a professor of healthcare management, was one of three former LDI executive directors on a panel moderated by its current chief, Dan Polsky Gr'96. They explored how the business of medical care has changed in the last half-century, and some of the challenges and opportunities ahead. (Video is available at

Though the hefty fraction of gross domestic product that goes to healthcare looms large in such discussions, Mark Pauly, the Bendheim Professor of Health Care Management at Wharton, dismissed it as "the world's most pernicious measure of a country's efficiency of its healthcare system."

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Thursday, July 13, 2017

The weird power of the placebo effect, explained - Vox

Over the last several years, doctors noticed a mystifying trend: Fewer and fewer new pain drugs were getting through double-blind placebo control trials, the gold standard for testing a drug's effectiveness.

In these trials, neither doctors nor patients know who is on the active drug and who is taking an inert pill. At the end of the trial, the two groups are compared. If those who actually took the drug report significantly greater improvement than those on placebo, then it's worth prescribing.

When researchers started looking closely at pain-drug clinical trials, they found that an average of 27 percent of patients in 1996 reported pain reduction from a new drug compared to placebo. In 2013, it was 9 percent.

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Why Chocolate May Be Good for the Heart -

Eating chocolate has been tied to a reduced risk of heart disease. Now scientists have uncovered one possible reason.

Using data from a large Danish health study, researchers have found an association between chocolate consumption and a lowered risk for atrial fibrillation, the irregular heartbeat that can lead to stroke, heart failure and other serious problems. The study is in Heart.

Scientists tracked diet and health in 55,502 men and women ages 50 to 64. They used a well-validated 192-item food-frequency questionnaire to determine chocolate consumption. During an average 14 years of follow-up, there were 3,346 diagnosed cases of atrial fibrillation.

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When Your Doctor Is Fitter Than You Are - The New York Times

"I enjoy working out at the gym," declares one profile. "To keep myself fit, I like to hike, bike and exercise," says another.

These comments aren't part of a dating site. Rather, they come from physicians' online profiles that prospective patients view when they are looking for a new doctor.

There are good reasons doctors might strive to lead by example. "I practice what I preach by living healthy every day," declares one physician on Kaiser Permanente's online doctor search portal. Patients may trust or be inspired by such a doctor, the thinking goes. And if health care professionals fail to follow their own advice, they may be accused of hypocrisy.

But for some patients, particularly those battling weight issues, a doctor's declarations of personal fitness may not have the intended effect of attracting new patients. Instead, rather than inspiring them, it can drive them away.

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Saturday, July 8, 2017

The Smart-Medicine Solution to the Health-Care Crisis - WSJ

The controversy over Obamacare and now the raucous debate over its possible repeal and replacement have taken center stage recently in American politics. But health insurance isn't the only health-care problem facing us—and maybe not even the most important one. No matter how the debate in Washington plays out in the weeks ahead, we will still be stuck with astronomical and ever-rising health-care costs. The U.S. now spends well over $10,000 per capita on health care each year. A recent analysis in the journal Health Affairs by the economist Sean P. Keehan and his colleagues at the federal Centers for Medicare and Medicaid Services projects that health spending in the U.S. will grow at a rate of 5.8% a year through 2025, far outpacing GDP growth.


The Patient Wants to Leave. The Hospital Says ‘No Way.’ - The New York Times

Why would an older person essentially discharge himself from a hospital, defying a physician's recommendation and signing a daunting form that acknowledges he is leaving A.M.A. — against medical advice?

Attend the tale of William Callahan.

He nearly fainted last spring after walking down the block to visit a neighbor in his New Jersey suburb. At 82, he had a long history of cardiac problems and was several years into Alzheimer's disease, but remained mobile and sociable.

He quickly revived, but the neighbor called 911. His daughter, Dr. Eileen Callahan, a geriatrician at Mount Sinai Hospital in New York, met her dad at the local emergency room.

"He was fine, sitting up and chatting," she found. "CT scan, blood work, heart rate, vital signs — all totally normal." He'd probably gotten a bit dehydrated, she figured, and he insisted on going home.

Dr. Callahan promised the E.R. doctor that she'd stay with her father overnight to be sure he was O.K. No dice.

"The doc said no, he really should stay overnight to be monitored and to see the cardiologist in the morning and get cleared."

In hospitals, she knew, her father was prone to sleeplessness and delirium. In unfamiliar surroundings, he might fall.

Still, "I succumbed." The hospital provided an aide to stay with Mr. Callahan overnight until another daughter arrived in the morning.

It did not go well. Mr. Callahan paced for hours, peeled off the heart monitors and grew increasingly confused and agitated. By the next afternoon, despite family calls and complaints, the cardiologist had not materialized and the hospital still wouldn't discharge Mr. Callahan.

Dr. Callahan's sister was growing frantic. "I said, 'Maureen, just do it,'" Dr. Callahan said. "Sign him out."

Her sister signed the A.M.A. form that hospitals typically demand before releasing patients against physician recommendations, acknowledging that patients understand and assume the risks, medically and legally.

Mr. Callahan went home and went to sleep, but his physician daughter remains livid.

"He should have been discharged right from the E.R.," she said. "This was cookbook medicine, done without thinking. It was very adversarial."

Such events happen more commonly than one might think. Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges.

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Saturday, July 1, 2017

A Doctor’s View of Obamacare and Trumpcare from Rural Georgia | The New Yorker

Nineteen years ago, after medical school at Columbia University; a stint at Montefiore Medical Center, in the Bronx; and a period running homeless shelters in Times Square; Karen Kinsell moved to Fort Gaines, a tiny town in southwest Georgia, on the Alabama line. Fort Gaines is in Clay County, which is consistently ranked among the poorest of the hundred and fifty-nine counties in the state. It currently ranks third-to-last in "health outcomes," according to the Robert Wood Johnson Foundation, up from dead last. Clay County's only hospital closed its doors in 1983, long before Kinsell, who is now in her sixties, arrived and became its only doctor. "It's a bad place to live," Kinsell said recently by phone, between seeing patients, "which is why I moved here. I was looking for a place that needed me."

Kinsell runs Clay County Medical Center, a facility with four exam rooms built out of a former Tastee-Freez. It's a private practice, but she is a full-time volunteer. There is a receptionist and two other full-time staff members; they see "around thirty to thirty-five patients a day," Kinsell said. Monty Veazey, the president of the Georgia Alliance of Community Hospitals, told me that "Kinsellcare" is the only health care that's had a meaningful and positive effect here. "She's going bankrupt treating everyone that comes in," he said. "Most have no money, no Internet access, no other basic care. Many don't have insurance. How much longer can she do that? I don't know. But she's their only hope."

On Tuesday, shortly before Senator Mitch McConnell announced a delay in the vote for the Senate Republicans' health-care reform bill, Kinsell spoke by phone about the effects of Obamacare, the prospect of Trumpcare, and the plight of sick people in southwest Georgia. Her account has been edited and condensed.

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Wednesday, June 28, 2017

How ‘Wellness’ Became an Epidemic - New York Magazine

Why are so many privileged people feeling so sick? Luckily, there's no shortage of cures.

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The Lab Says It’s Cancer. But Sometimes the Lab Is Wrong. - The New York Times

It was the sort of bad news every patient fears. Merlin Erickson, a 69-year-old retired engineer in Abingdon, Md., was told last year that a biopsy of his prostate was positive for cancer.

Mr. Erickson, worried, began investigating the options: whether to have his prostate removed, or perhaps to have radiation treatment. But a few days later, the doctor called again.

As it turned out, Mr. Erickson did not have cancer. The lab had mixed up his biopsy with someone else's.

"Obviously, I felt great for me but sad for that other gentleman," Mr. Erickson said.

The other gentleman was Timothy Karman, 65, a retired teacher in Grandy, N.C. At first, of course, he had been told he was cancer-free. The phone rang again a few days later with news of the mix-up and a diagnosis of cancer.

Ultimately he had his prostate removed. "I said, 'Mistakes happen,'" Mr. Karman said.

They may be happening more often than doctors realize. There is no comprehensive data on how often pathology labs mix up cancer biopsy samples, but a few preliminary studies suggest that it may happen to thousands of patients each year.

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Doctor on demand: How app culture is reviving the house call - The Washington Post

Alison Mintzer and her family were on a flight from New York to Los Angeles when her daughter complained that she felt sick. By the time they landed, Mintzer's normally uncomplaining 6-year-old said that her neck and ears hurt. When a fever soon followed, it was enough to convince her parents that she needed to see a doctor.

Thousands of miles from their pediatrician, and unable to find one quickly in L.A., Mintzer didn't know what to do. Then a family friend suggested an app called Heal that could use new technology to drum up a relic from the past: doctors who make house calls.

Once upon a time, a visit with the doctor meant welcoming one into your home, rather than heading out to a clinic or hospital waiting room. But around the 1960s, the house call fell out of favor as doctors' offices sought to become more efficient, and the doctor-patient relationship changed from "Marcus Welby" to something less personal with the rise of hospitals and modern insurance plans.

Now, however, the trend for on-demand service in the age of Uber could revive the house call. Services such as Heal — which launched in the District in June after operating in California since 2014 — and competitors such as Pager and Curbside Care are expanding their footprints across the country. And research suggests that house calls can provide a better standard of care for some patients than a hospital visit. A University of Southern California study of a house call program in the state found that hospitalization rates dropped for patients who were enrolled in the program for six months: Of 1,000 patients, 96 were hospitalized after being enrolled, down from 159 before the program.

Costs can also drop, since patients can avoid hospital visits. A 2013 Brookings Institution report said a Department of Veterans Affairs analysis of its home-based care program found a "25 percent reduction in hospital admissions, a 36 percent reduction in hospital days, and a 13 percent reduction in combined costs."

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