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Economic Incentives Motivate: What We Can Learn From The Rand Health Insurance Experiment

The use of economic incentives to motivate behavior is neither a Democratic or Republican idea. It is human nature to be motivated by economic incentives. The concept of individual responsibility is an American idea. It has been tarnished in recent years.

There is no question in my mind that government has the responsibility to be compassionate and help the needy. It is my view that government should help individuals help themselves.

The costs associated with Medicare and traditional healthcare insurance are rising. Every stakeholder points a finger at the other stakeholders as the cause.

President Obama’s Healthcare Reform Act is raising costs higher in anticipation of cuts in the future. He is in the process of forcing individuals to be more dependent on the government rather than promoting individual responsibility.

Obamacare will fail to control costs.

All anyone has to do is look at a Rand Corp. study of 29 years ago to see what works and what doesn’t work. Read more »

*This blog post was originally published at Repairing the Healthcare System*

Consumer-Directed Healthcare Leader, OptumHealth, Wants To Influence How Patients Choose Their Care

robwebb1OptumHealth is one of the largest health and wellness companies in the United States, providing services to about 58 million people. It is the umbrella organization for 12 consumer-directed healthcare companies recently purchased by UnitedHealth Group. I caught up with the CEO of OptumHealth Care Solutions, Rob Webb, at Health 2.0 to find out what they’re up to and how they’re hoping to contribute to healthcare reform.

Dr. Val: What does Optum Health do?

Webb: We work with about 300,000 people a day. We’re focused on the consumer-provider interaction and we try to help consumers make better decisions in four key areas: 1) help them find the right provider for their needs,  2) to provide them with an unbiased set of information about what their treatment options are 3) optimize their pharmaceutical regimens and medication compliance and 4) help them improve their lifestyle choices. In the past we focused a lot of our efforts on #3 because it’s so tangible and there’s an entire PBM (pharmacy benefits management) industry to help. Read more »

The Center For Connected Health: Patients Should Be Their Own Primary Care Providers

Dr. Joe Kvedar is the Residency Program Director of the Department of Dermatology at Harvard Medical School. He is also the Founder and Director of the Center for Connected Health, an organization whose provocative goal is to help patients “become their own primary care provider.” I caught up with Dr. Kvedar at a recent health conference, and asked him to explain what his company’s approach contributed to the healthcare landscape.

Dr. Val: What is the Center for Connected Health?

Dr. Kvedar: Connected Health’s mission is to empower patients to be maximally in control of their own health destiny. As much as possible, we’d like to see patients become their own primary care provider.

There are three principles that must work together to accomplish this: first you must have accurate information about the health behavior that you want to change. Measurements must rely on quantifiable data (like the step count of a pedometer) rather than more general self-reports of how physically active you are.  Second, the report must be in a format that offers specific feedback to the individual. Trending of information is critical, but the trends must be understood in context. For example a patient with diabetes needs to see how their blood glucose levels are behaving over time, but more than that they need to see how their food intake was influencing these levels. And third, data-driven coaching inspires the application of data to real lifestyle improvements.

Giving accurate information about yourself (in a format that is contextually trended over time) to a person that you trust can inspire behavior change. People are more likely to change their unhealthy choices when they know they’re accountable to someone for them. An appropriate coach can be anyone from a friend in a social network to a digital avatar, to a doctor or nurse.

Dr. Val: So what’s the rate limiting step in getting this behavior change model adopted? Is it lack of financial incentives?

Dr. Kvedar: That’s certainly part of it, but it’s even more than that. Healthcare providers gravitate towards human resource-intensive solutions. Providers are simply not used to thinking of technology as a tool. Instead, they often perceive the solution to better patient compliance as an increase in staff to serve them. But this is not feasible given our provider shortage and increasing healthcare burden. It’s just really hard for doctors to imagine that patients could be coached effectively by an avatar, yet there are many examples of it working. Read more »

Consumer-Generated Clinical Trials? Research Minus Science = Gossip

The internet, in democratizing knowledge, has led a lot of people to believe that it is also possible to democratize expertise.

- Commenter at Science Based Medicine

Regular readers of this blog know how passionate I am about protecting the public from misleading health information. I have witnessed first-hand many well-meaning attempts to “empower consumers” with Web 2.0 tools. Unfortunately, they were designed without a clear understanding of the scientific method, basic statistics, or in some cases, common sense.

Let me first say that I desperately want my patients to be knowledgeable about their disease or condition. The quality of their self-care depends on that, and I regularly point each of my patients to trusted sources of health information so that they can be fully informed about all aspects of their health. Informed decisions are founded upon good information. But when the foundation is corrupt – consumer empowerment collapses like a house of cards.

In a recent lecture on Health 2.0, it was suggested that websites that enable patients to “conduct their own clinical trials” are the bold new frontier of research. This assertion betrays a lack of understanding of basic scientific principles. In healthcare we often say, “the plural of anecdote is not data” and I would translate that to “research minus science equals gossip.” Let me give you some examples of Health 2.0 gone wild:

1. A rating tool was created to “empower” patients to score their medications (and user-generated treatment options) based on their perceived efficacy for their disease/condition. The treatments with the highest average scores would surely reflect the best option for a given disease/condition, right? Wrong. Every single pain syndrome (from headache to low back pain) suggested a narcotic was the most popular (and therefore “best”) treatment. If patients followed this system for determining their treatment options, we’d be swatting flies with cannon balls – not to mention being at risk for drug dependency and even abuse. Treatments must be carefully customized to the individual – genetic differences, allergy profiles, comorbid conditions, and psychosocial and financial considerations all play an important role in choosing the best treatment. Removing those subtleties from the decision-making process is a backwards step for healthcare.

2. An online tracker tool was created without the input of a clinician. The tool purported to “empower women” to manage menopause more effectively online. What on earth would a woman want to do to manage her menopause online, you might ask? Well apparently these young software developers strongly believed that a “hot flash tracker” would be just what women were looking for. The tool provided a graphical representation of the frequency and duration of hot flashes, so that the user could present this to her doctor. One small problem: hot flash management is a binary decision. Hot flashes either are so personally bothersome that a woman would decide to receive hormone therapy to reduce their effects, or the hot flashes are not bothersome enough to warrant treatment. It doesn’t matter how frequently they occur or how long they last. Another ill-conceived Health 2.0 tool.

When it comes to interpreting data, Barker Bausell does an admirable job of reviewing the most common reasons why people are misled to believe that there is a cause and effect relationship between a given intervention and outcome. In fact, the deck is stacked in favor of a perceived effect in any trial, so it’s important to be aware of these potential biases when interpreting results. Health 2.0 enthusiasts would do well to consider the following factors that create the potential for “false positives”in any clinical trial:

1. Natural History: most medical conditions have fluctuating symptoms and many improve on their own over time. Therefore, for many conditions, one would expect improvement during the course of study, regardless of treatment.

2. Regression to the Mean: people are more likely to join a research study when their illness/problem is at its worst during its natural history. Therefore, it is more likely that the symptoms will improve during the study than if they joined at times when symptoms were not as troublesome. Therefore, in any given study – there is a tendency for participants in particular to improve after joining.

3.  The Hawthorne Effect: people behave differently and experience treatment differently when they’re being studied. So for example, if people know they’re being observed regarding their work productivity, they’re likely to work harder during the research study. The enhanced results therefore, do not reflect typical behavior.

4. Limitations of Memory: studies have shown that people ascribe greater improvement of symptoms in retrospect. Research that relies on patient recall is in danger of increased false positive rates.

5. Experimenter Bias: it is difficult for researchers to treat all study subjects in an identical manner if they know which patient is receiving an experimental treatment versus a placebo. Their gestures and the way that they question the subjects may set up expectations of benefit. Also, scientists are eager to demonstrate positive results for publication purposes.

6. Experimental Attrition: people generally join research studies because they expect that they may benefit from the treatment they receive. If they suspect that they are in the placebo group, they are more likely to drop out of the study. This can influence the study results so that the sicker patients who are not finding benefit with the placebo drop out, leaving the milder cases to try to tease out their response to the intervention.

7. The Placebo Effect: I saved the most important artifact for last. The natural tendency for study subjects is to perceive that a treatment is effective. Previous research has shown that about 33% of study subjects will report that the placebo has a positive therapeutic effect of some sort.

In my opinion, the often-missing ingredient in Health 2.0 is the medical expert. Without our critical review and educated guidance, there is a greater risk of making irrelevant tools or perhaps even doing more harm than good. Let’s all work closely together to harness the power of the Internet for our common good. While research minus science = gossip, science minus consumers = inaction.

How is Healthcare Like A Garden Fungus?

Hot and humid weather has spurred on the growth of many of my outdoor plants, including bamboo, rosemary, and various peonies. However, I was unpleasantly surprised by the arrival of three fungal guests, only one of which I could identify: the dog stinkhorn. As its name suggests, it is one unpleasant-smelling organism. A certain mushroom website described it as looking like “a dog phallus dipped in excrement.” They are not too far off. But sadder still was the assertion that there is no known cure for this fungal invader.

As I considered my new mushroom issue, I suddenly realized that there are interesting parallels with the healthcare system. Let me explain.

First of all, what does the average person do when they experience a new medical symptom/problem? The person goes online to research the symptom for possible diagnoses and treatment options. Is s/he successful? Sometimes yes and sometimes no. In my case, I could only identify one of the three types of fungi in my garden, even after finding this very nice mushroom identifier tool. Why wasn’t I successful? I’m not a fungi expert, and really didn’t know how to navigate my way through the complex descriptors required to correctly identify the little beasts. The questions included the following:

Fungus Website (FW): Is the spore color olivacious?

Dr. Val: What part of the mushroom is the spore, and what kind of olive are you referring to? I don’t know how to answer that.

FW: Describe the stem type. Is it lateral, rudimentary, or absent? Does it have a volva?

Dr. Val: Um… If the stem is lateral, does that mean it’s sticking out of the side of the mushroom? What makes a stem rudimentary? Does that just mean it’s not fancy? And as for the last question… that sounds kind of pornographic and I don’t think I’d know a fungus volva if I saw one.

FW: Can the pore material be separated from the flesh of the cap?

Dr. Val: What’s pore material?

FW: Is the mushroom edible, hallucinogenic, or poisonous/suspect?

Dr. Val: Well, it definitely looks “suspect” but there’s no way I’m going to test it out for poisonous or hallucinogenic effects.

And so it went. I tried to answer some of the identifier questions to get me to the correct fungal I.D. and in the end I received this message, “we were unable to find a match for your search.”

When patients try to find a diagnosis for their symptoms online, they will inevitably have a similar experience. Medical speak is like a foreign language, subtle differences between signs and symptoms seem obvious to experts, but can be opaque to patients. And even a very bright and educated consumer is bound to get lost in figuring out appropriate next steps. I’m a savvy woman, but when it comes to mycology (the study of fungus), I’m completely lost. How much more complicated is it to navigate the subject of human disease for those who don’t have formal training in medicine?

My point is this – medicine is incredibly complex, and a knowlegeable heatlhcare provider is critical in helping patients successfully navigate the maze. With all the health information on the Internet, it’s tempting to self-diagnose. But that’s a dangerous proposition – one that might lead you to presume that (to use my analogy) a poisonous mushroom is edible, or that a life threatening symptom is innocuous.

The Internet can be a great educational tool, but use it in conjunction with a close relationship to a trusted expert. If you don’t have a primary care physician, you can find one here. If you’d like to have your question answered by a physician online, try the Revolution Health forums. Not every question is selected for a professional reply, but many are. For a guaranteed response, eDocAmerica is a great resource.

Good luck, and I hope that your garden remains fungus-free. I’m now going to try to find a mycologist to tell me if it’s really true that there’s “no cure” for the dog stinkhorn. Unless any of you know the answer?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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