Shopping for Health Care: A Fledgling Craft - The New York Times

Four years ago, Dave deBronkart spoke at a medical conference, with his face displayed on a giant screen. Afterward, a doctor told him that a spot on his face looked like basal cell carcinoma.

She was right. That cancer was unlikely to spread, but it needed to be treated, and deBronkart's health insurance policy had a $10,000 deductible. Any treatment, then, would come out of his pocket. How would he find the right treatment at the right price?

The reason deBronkart was attending the conference was that he is an advocate for patient involvement in health care. So he decided that, as an experiment, he would invite proposals on his blog, e-PatientDave. He outlined what he was looking for and asked health care providers to bid for his business.

No one did, of course. "I didn't expect to get a response," he said. "Hospitals don't have a 'submit a bid' department. But you hear over and over that patients are the reason for high health costs. I pursued it as far as I could to explore what happened when a patient tries to be a responsible consumer."

He began calling around to hospitals asking the price of various procedures. "The hospitals said 'we don't know; ask your insurance company.' The insurance company said 'we don't know; ask your hospital,'" said deBronkart. "That was when I smelled a great big rat."

After many, many calls, he chose his surgery: excision, total price $868. Today he is fine.

But his point stands: Health care operates very differently from anything else we buy.

"The actual information I needed in order to be an effective, responsible shopper was by policy blocked from me," he said in an interview. "It's not just a matter of lowering costs. It blocks innovation. Somebody does a good job — better quality, better price — but there's no way for people to discover them."

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http://opinionator.blogs.nytimes.com/2016/04/12/shopping-for-health-care-a-fledgling-craft/?

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$250 million, 300 scientists and 40 labs: Sean Parker’s revolutionary project to ‘solve’ cancer - The Washington Post

Billionaire Sean Parker, famous for his founding roles at Napster and Facebook, is backing an unconventional $250 million effort to attack cancer that involves persuading hundreds of the country's top scientists — who often are in competition with each other — to join forces and unify their research targets.

The consortium, which was formally announced Wednesday, focuses on immunotherapy, a relatively new area of research that seeks to mobilize the body's own defense systems to fight mutant cancer cells. Many believe it represents the future of cancer therapy.

More than 300 scientists working at 40 labs in six institutions — Stanford, the University of California, San Francisco, and University of California, Los Angeles, the University of Pennsylvania, MD Anderson Cancer Center and Memorial Sloan Kettering Cancer Center — have already signed on.

"Cancer immunotherapy is such an incredibly complex field, and for every answer it seems to pose 10 more questions. I'm an entrepreneur so I wish some of these questions had been answered yesterday," Parker said.

He describes the effort as a way to remove obstacles related to bureaucracy and personality that will allow scientists to borrow from each other's labs unencumbered. The researchers will continue to be based at their home institutions but will receive additional funding and access to other resources, including specialized data scientists and genetic engineering equipment set to become part of the nonprofit Parker Institute for Cancer Immunotherapy in San Francisco.

A centralized scientific steering committee comprised of one member from each participating university will set the group's research agenda and coordinate data collection and clinical trials across the many sites.

In designing this new model, the 36-year-old Parker has taken a page from his experience as an entrepreneur by thinking beyond early research to actual therapies that he believes could eventually benefit millions of people in the United States and abroad.

One of his central innovations — and the one that initially made some university partners uncomfortable — is that the institute will take the lead in licensing and negotiating with industry to bring any therapies to market. The researchers and academic centers will still continue to own the intellectual property.

"This allows us to run a much more competitive negotiation with industry. We would become a kind of one-stop shop for the technology," he said.

The new institute will be led by Jeff Bluestone, the respected former University of California, San Francisco, provost and immunologist who is one of 28 members of a blue-ribbon experts panel recently named by Vice President Biden to advise the government's $1 billion "moonshot" initiative to cure cancer.

Bluestone thinks collaboration changes the ambitions of everyone in the field. "Having lived in a world of individualized, solo research, I can see that the thinking is different," he said. "It's about how we can all do something bigger and better together."

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https://www.washingtonpost.com/news/to-your-health/wp/2016/04/13/250-million-300-scientists-and-40-labs-sean-parkers-revolutionary-project-to-solve-cancer/

The Undeniable Convenience and Reliability of Retail Health Clinics - The New York Times

My wife and I both work. When one of our children wakes up complaining of a sore throat, we could begin a ritual stare-down to determine which of us is going to have to wait for the doctor's office to open, make the phone call, wait on hold, schedule an appointment (which will inevitably be in the middle of the day), take off work, pick up the child from school, sit in the waiting room (surrounded by other sick children), get the rapid strep test, find out if the child is infected and then go to the pharmacy or back to school, before returning to work.

Or, one of us could just take the child to a retail clinic on the way to work and be done in 30 minutes. Strep throat is incredibly easy to treat (Penicillin still works great!). There's a simple and very fast test for it. Moreover, physicians are really bad at diagnosing it clinically. A study found that a doctor's guess as to whether pharyngitis, or a respiratory infection for that matter, is bacterial or viral is right about 50 percent of the time — no better than flipping a coin. The point is, you need to get the rapid strep test every time regardless, no matter the location.

Aimee and I choose the retail clinic every time.

Why? Convenience is the biggest reason. Many doctors' offices are open only on weekdays and during business hours. This also happens to be when most adults work and when children attend school. A 2010 survey of 11 countries found that Americans seek out after-hours care or care in a hospital's emergency room more often than citizens of almost any other industrialized nation. More than two-thirds of Americans with a below-average income did so. But this isn't just a problem for the poor. About 55 percent of those with an above-average income did so as well.

We complain all the time that people use the emergency room for primary care. But that's not always about lack of insurance. It's about access. The emergency room is open when people can actually go. Emergency room use has gone up, not down, since the passage of the Affordable Care Act. More people have insurance, and now can afford care when they need it.

That care is also coming from retail clinics, usually found either in stand-alone storefronts or inside pharmacies. Between 2007 and 2009, retail clinic use increased 10-fold. It turns out that my wife and I represent America pretty well. About 35 percent of retail visits for children are for pharyngitis — sore throats. Add in ear infections and upper respiratory infections, and you've accounted for more than three-quarters of visits for children. Parents bring their children to retail clinics to take care of quick, acute problems. Swap ear infections for immunizations, and you've got the main reasons adults use retail clinics, too.

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http://www.nytimes.com/2016/04/13/upshot/the-undeniable-convenience-and-reliability-of-retail-health-clinics.html?

The Pain Gap: Why Doctors Offer Less Relief to Black Patients - The Daily Beast

A new University of Virginia study suggests that many medical students and residents are racially biased in their pain assessment, and that their attitudes about race and pain correlate with falsely-held beliefs about supposed biological differences—like black people having thicker skin, or less sensitive nerve endings than white people—more generally.

The study highlights how a confluence of mistaken attitudes—about race, about biology, and about pain—can flourish in one of the worst possible places: medical schools where the future gatekeepers of relief are trained. And it illuminates what I've called the divided state of analgesia in America: overtreatment of millions of people that feeds painkiller abuse at the same time that, with far less public attention, millions of others are systematically undertreated. Think of it as a pain gap between the haves and the have-nots, along lines of class and race.

Unfortunately, the UVA findings are neither surprising nor fundamentally new. Back in the 1990s, two studies—one in an Atlanta emergency room, the other in Los Angeles—found that white patients being treated for long bone fractures were dosed more liberally than Latino patients in L.A., and more liberally than black ones in Atlanta. The authors put forward several possible explanations of the disparity: Perhaps patients in different groups expressed pain differently, or maybe caregivers interpreted pain differently in these groups, or perhaps nurses and doctors saw pain the same way across groups but just chose to remedy pain differently.

By the late 1990s, other studies found similar disparities in cancer care, where people receiving outpatient cancer care in places that mostly served minorities were three times more likely to be under-medicated with analgesics than patients in other settings. Speculation about the causes deepened: Perhaps inadequate prescribing for minority patients resulted from concerns about potential drug abuse, or maybe minority patients had more difficulty finding pharmacies that stocked opioid prescriptions, or again perhaps there was a cultural barrier in doctor-patient understanding and assessment. Into the 2000s, additional reports have confirmed the gap—again with no agreement about any single cause.

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http://www.thedailybeast.com/articles/2016/04/11/the-pain-gap-why-doctors-offer-less-relief-to-black-patients.html?

As white women between 25 and 55 die at spiking rates, a close look at one tragedy | The Washington Post

They had been expecting a full processional with a limousine and a police escort, but the limousine never came and the police officer was called away to a suspected drug overdose at the last minute. That left 40 friends and relatives of Anna Marrie Jones stranded outside the funeral home, waiting for instruction from the mortician about what to do next. An uncle of Anna's went to his truck and changed from khakis into overalls. A niece ducked behind the hearse to light her cigarette in the stiff Oklahoma wind.

"Just one more thing for Mom that didn't go as planned," said Tiffany Edwards, the youngest surviving daughter. She climbed into her truck, put on the emergency flashers and motioned for everyone else to follow behind in their own cars. They formed a makeshift processional of dented pickups and diesel exhaust, driving out of town, onto dirt roads and up to a tiny cemetery bordered by cattle grazing fields. In the back there was a fresh plot marked by a plastic sign.

"Anna Marrie Jones: Born 1961 — Died 2016."

Fifty-four years old. Raised on three rural acres. High school-educated. A mother of three. Loyal employee of Kmart, Walls Bargain Center and Dollar Store. These were the facts of her life as printed in the funeral program, and now they had also become clues in an American crisis with implications far beyond the burnt grass and red dirt of central Oklahoma.

White women between 25 and 55 have been dying at accelerating rates over the past decade, a spike in mortality not seen since the AIDS epidemic in the early 1980s. According to recent studies of death certificates, the trend is worse for women in the center of the United States, worse still in rural areas, and worst of all for those in the lower middle class. Drug and alcohol overdose rates for working-age white women have quadrupled. Suicides are up by as much as 50 percent.

What killed Jones was cirrhosis of the liver brought on by heavy drinking. The exact culprit was vodka, whatever brand was on sale, poured into a pint glass eight ounces at a time. But, as Anna's family gathered at the gravesite for a final memorial, they wondered instead about the root causes, which were harder to diagnose and more difficult to solve.

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http://www.washingtonpost.com/sf/national/2016/04/08/we-dont-know-why-it-came-to-this/?

A new divide in American death: Statistics show widening urban-rural health gap | The Washington Post

White women have been dying prematurely at higher rates since the turn of this century, passing away in their 30s, 40s and 50s in a slow-motion crisis driven by decaying health in small-town America, according to an analysis of national health and mortality statistics by The Washington Post.

Among African Americans, Hispanics and even the oldest white Americans, death rates have continued to fall. But for white women in what should be the prime of their lives, death rates have spiked upward. In one of the hardest-hit groups — rural white women in their late 40s — the death rate has risen by 30 percent.

The Post's analysis, which builds on academic research published last year, shows a clear divide in the health of urban and rural Americans, with the gap widening most dramatically among whites. The statistics reveal two Americas diverging, neither as healthy as it should be but one much sicker than the other.

In modern times, rising death rates are extremely rare and typically involve countries in upheaval, such as Russia immediately after the collapse of the Soviet Union. In affluent countries, people generally enjoy increasingly long lives, thanks to better cancer treatments; drugs that lower cholesterol and the risk of heart attacks; fewer fatal car accidents; and less violent crime.

But progress for middle-aged white Americans is lagging in many places — and has stopped entirely in smaller cities and towns and the vast open reaches of the country. The things that reduce the risk of death are now being overwhelmed by things that elevate it, including opioid abuse, heavy drinking, smoking and other self-destructive behaviors.

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http://www.washingtonpost.com/sf/national/2016/04/10/a-new-divide-in-american-death/?