Q3 Spring 2008
Can good health be good business?
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Comment from How can we fund innovation?
The innovation in the medical devices is also restricted because of the lack of coverage or delay in coverage for any innovative technology. For instance the device manufacturers first have to search the coding for some similar technology or device and if it is not there then the manufacturer have to wait for a long period of around a year. These delays actually discourage the manufacturers in coming up with some true innovation which is highly required in today's scenario. As the faster the devices or technology gets the coverage for its reimbursement by CMS, faster will be the adoption by the healthcare providers (hospitals).
Request for some comment over it.
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How can we fund innovation?
Comment from Does our health system deliver value?
The New York Times takes a look at the consequences uncertainty around healthcare reform could be having on innovation in the United States.
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Comment from Listening to patients and staff
The Geary Behavioural Economics blog points out that with populations both aging and mobile in a way that scatters families, loneliness will be a defining issue for both society and the economy in coming years. The post points to a new book by John T. Cacioppo on the broad impacts of loneliness and to a thoughtful commentary about the book and the economics of loneliness by Edward T. Glaeser in the New York Times Economix blog.
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Comment from What is the return on a life saved?
“At what point is the cost of medical care to extend life not justified?” The Baseline Scenario blog takes up this thorny question and points to several interesting discussions.
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What is the return on a life saved?
Comment from Does our health system deliver value?
Much of the debate around healthcare reform has focused on maintaining the market mechanism, but, according to the blog TPMMuckraker, “the notion that most American consumers enjoy anything like a competitive marketplace for health care is flatly false.” The post goes on to cite a report by the American Medical Association showing 94% of the insurance markets can be categorized as "highly concentrated," prompting some to call for antitrust investigations.
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Does our health system deliver value?
Comment from Should employers be responsible for health?
New research from McKinsey offers details on the widening disparity in healthcare. While the highest income levels are seeing both rising income and increasing employer-sponsored healthcare benefits, those "in the bottom-income category (earning an average of $14,800 a year), incomes have been stagnant, and their employers are less likely to pay for their health insurance. This group is finding any healthcare difficult, if not impossible, to afford."
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Comment from Can good health be good business?
Despite opposing it during the campaign, President Obama has put the taxing of some employee health benefits back on the table as a way to pay for healthcare reform, according to an article in the New York Times.
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Can good health be good business?
Comment from Does our health system deliver value?
The recently passed $787 billion economic stimulus bill set aside $1.1 billion for the federal government to compare the effectiveness of different treatments for the same illness. According to a New York Times article, “The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.” But the program is controversial, and is viewed by many as a precursor to future battles over healthcare reform.
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Comment from Can good health be good business?
Rating doctors is an idea that has been popular for some time with advocates of market-based reforms to the healthcare system. Now Zagat, of restaurant guide fame, has gotten into the act in collaboration with the insurance company Wellpoint; the New York Times explains.
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Comment from Does universal healthcare make everyone's life better?
universal health care
you hear a lot of talk about tax increases if we were to switch to a universal health care......Those increases seem minimal if not less then what the average American is already paying for health coverage....I consider myself one of the lucky few, my health insurance for a family of five is costing me around $300 a month, i would gladly pay this amount in increased taxes if that meant universal coverage for everyone....my $300 a month does not include my 3000 dollar deductible that I must pay out of pocket every year and not to mention my $25 dollar co-pay when I go and see my Doctor......The proof is in the pudding universal health care works.....but are corrupt senators and members of congress would rather get rich off of insurance groups then see a healthy nation?
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Does universal healthcare make everyone's life better?
Comment from How can we fund innovation?
Dick Foster, a senior faculty fellow at SOM, talks with the McKinsey Quarterly about this how the financial crisis is another cycle of creative destruction. The idea, initially proposed by economist Joseph Schumpeter called for companies to change at the pace and scale of the capital markets, without losing control of ongoing operations.
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Comment from Can an international perspective help create a value-based health system?
A McKinsey Quarterly report highlights healthcare in the United States. It calculates that the country spends $650 billion more on health care than might be expected given the country’s wealth and the experience of comparable OECD members. “For health care reform to generate lasting improvements in cost, quality, access, and equity, it must effectively address supply, demand, and payment,” the report states, adding “without the involvement of all major stakeholders (such as hospitals, payers, and doctors) reform is likely to prove elusive.”
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Can an international perspective help create a value-based health system?
Comment from Should employers be responsible for health?
A viewpoint article in Businessweek argues that universal healthcare would be just the sort of economic stimulus the United States could use.
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Comment from Can an international perspective help create a value-based health system?
Professor Marmor, many thanks for your response. I agree that value-based care delivery and reimbursement is a lofty goal, and one that has yet to be achieved on a system-wide basis. We hope that studying examples of individual organizations and health care systems that do incorporate value-based principles will inform methods of moving both organizations and ultimately systems toward value-based models.
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Alex Peterson
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Can an international perspective help create a value-based health system?
Comment from How can we fund innovation?
Zen Chu gives a really great presentation to Harvard Medical School physicians and MIT engineers on a framework for identifying and funding medical innovation. It's titled "High Impact Medical Innovation." He maps a landscape for determining which innovations are products, which are venture capital-backed companies, which are appropriate for large companies and which ones must likely start as philanthropic. Zen also gives techniques for inventing better solutions which maximize clinical impact, physician adoption and acceleration to market. A terrific contribution to helping spur much needed medical innovation!
http://cimit.typepad.com/cimit_forum_blog/2008/05/inventing-high.html
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R Davis
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Comment from Hospital management in Ethiopia
The program to bring change in Ethiopian hospital management is very nice. So to achieve the desired goal at the same time in all hospitals, please try to train all CEOs at the same time this year. Because we can see the same change in all hospitals at the same time. Above all, yale university must take great responsibility for training CEO than jimma university because some teachers in jimma university uses unnessesary and unrelated entrance exam and unrelated teaching methodology.
THANKS FOR CLINTON AND YALE UNIVERSITY/ GOD BLESS YOU /
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Hospital management in Ethiopia
Comment from How can technological innovation help healthcare?
Healthcare has a lot to gain in terms of both quality of care and business opportunities from taking advantage of information that is already available. “Experts say that the United States wastes billions of dollars annually on medical treatments which may not work. But the financial and human consequences are also large when evidence exists but is not collected,” according to a New York Times feature on the down-side of not having outcomes tracking.
In one example of information-system improvement (which also illustrates how difficult it can be to implement large-scale change), New Jersey doctors will be able to share patient imaging through a secure web portal. A story in HealthcareIT News describes the year-long trial of the New Jersey Health Information Exchange. The program aims to expand to other sorts of medical records in 2009.
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How can technological innovation help healthcare?
Comment from Should employers be responsible for health?
Is Medicare the key to universal coverage? Yale SOM professor emeritus Ted Marmor co-wrote a posting on the Health Affairs blog with Merton Bernstein of Washington University. The piece argues that a Medicare-for-All plan would provide universal coverage, cost no more than what we already spend on healthcare, eliminate insurer and employer-sponsored conflicts of interest, and let practitioners focus on delivering healthcare. The authors write, “Medicare makes the most practical platform for both extending coverage and taming medical cost inflation… Medicare has been on the job for more than four decades and has resolved hundreds of practical problems that any large-scale health program must address.”
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Comment from Does our health system deliver value?
Is the push to produce price and quality transparency yielding results? Not yet, according to a study by the Center for Health System Change. Health plans rarely offer consumers incentives for using what data is available. A story in HealthcareIT News quotes the study co-author saying, "We're a long way from a critical mass of consumers trusting and using the information to choose physicians and hospitals."
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Comment from Does our health system deliver value?
A McKinsey report finds that the days of the full-service general hospital are numbered. It suggests that hospitals can no longer be all things to all people. The success of small specialized facilities and increasing transparency on quality are forcing generalist facilities to choose where to compete.
An essay from Jennifer Baron in Q3 offers details on the value-based healthcare model implicit in McKinsey’s finding.
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Comment from What is the return on a life saved?
The incidence of HIV infection may be 40% higher than previously estimated, according to a new report by a team of CDC researchers that included Yale professor Edward H. Kaplan. A summary of the work is available in the New York Times. The CDC has also prepared a fact sheet on the research. And the original paper, “Estimation of HIV Incidence in the United States,” is available from the Journal of the American Medical Association.
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Comment from Can an international perspective help create a value-based health system?
Professor Marmor, many thanks for your response. I agree that value-based care delivery and reimbursement is a lofty goal, and one that has yet to be achieved on a system-wide basis. We hope that studying examples of individual organizations and health care systems that do incorporate value-based principles will inform methods of moving both organizations and ultimately systems toward value-based models.
We are working on a series of case studies highlighting organizations making progress in various aspects of care delivery, including outcomes measurement, that put some concrete experiences behind the hopes and theories (http://www.hbs.edu/rhc/health_care_delivery_curriculum.html).
Linking outcomes to costs is difficult (though we believe not impossible) with the current care delivery and reimbursement structures, and our primary focus so far has been on the outcomes numerator of the value equation. There does seem to be an encouraging number of examples of successful, albeit imperfect, outcomes measurement initiatives.
Professor Okma, I’d welcome the chance to learn from your experience and perspective, and would love to read some of the publications listed on your website.
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Jennifer Baron
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Can an international perspective help create a value-based health system?
Comment from Does our health system deliver value?
In an op-ed on HBS’s Working Knowledge website, Michael Porter takes a new tack on the financial interest employers have in healthcare. “Employers cannot get out of health care, no matter what kind of health insurance system is put in place. They bear the cost of poor health in the form of sick days, absenteeism, reduced productivity at work…. Employers spend 200 to 300 percent more on the indirect costs of poor health than they do on health benefits.”
Dr. Atul Gawande delivers an accounting of the process improvements, cost savings, and improved outcomes from the “ridiculously primitive insights” offered by the under-appreciated checklist in the New Yorker.
Trying to address the $100 billion cost associated with non-adherence to medication regimes, the Boston-based HealthHonors has devised an interactive system that rewards patients for improved compliance with their prescribed medication schedule. They are beginning a year-long study in association with Yale University Medical School, according to a story in Healthcare IT News.
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Comment from Does our health system deliver value?
I cannot believe that researchers are still citing the RAND health insurance experiment since it has been shown that its results may be a spurious artifact of attrition bias from this experiment (Nyman, 2007). Because of design flaws in this experiment, researchers have had to use observational econometric techniques in analysis of the resulting data. This study can no longer be referred to as a truly randomized experiment and its conclusions regarding the impact of health insurance on spending and outcomes are sensitive to modeling specifications.
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Does our health system deliver value?
Comment from Does our health system deliver value?
I sell a program that is like a transplant centers of excellence program - except it is for Knee Replacement, Spine, Cancer, & Bypass Surgery. The 8 hospitals in the program are top rated "Focus Factories." Pricing is 1 BILL, 1 PAYMENT.... episode of care pricing in the purest sense. Complications to 200% of the DRG are included - providers standing behind their work. Our program is added to a self funded plan. Employees can stay in network, where infection, death & redo rates are often too high. Or they can come to one of our hospitals, all 5 star rated by HealthGrades (outcomes data). Employee: has no Deductible/OOP imposed - as the plan pays out 50% less; receives up to $4,000 recovery benefit; travel & 4 star hotel are included. The plan saves on average $20,000 per surgery. 1 infection avoided the plan can save an additional $100,000. Our program compliments the concept -- Cleveland Clinic Branch Hospital in every state. Until this happens, our FocusFactory hospitals fill the competition void that plauges our system.
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Does our health system deliver value?
Comment from Can an international perspective help create a value-based health system?
You might find it useful to have an email exchange with my wife, who writes about this subject (http://www.kiekeokma.nl/index.html). I think you would find the exchange useful.
The idea of aligning incentives around improving patient oucomes per unit of cost is appealing, very hard to do, and done nowhere. That makes the appeal to it, on an expected value basis, less compelling.
Ted Marmor
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theodore.marmor@yale.edu
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Can an international perspective help create a value-based health system?
Comment from Can an international perspective help create a value-based health system?
Great article. Very well written, and extremely interesting.
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Ashley
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Can an international perspective help create a value-based health system?
Comment from Does our health system deliver value?
In response to Nick, cost-sharing with patients can effect demand-driven increases in service use in industries that have transparent information. Healthcare's information is far from transparent for the patients or providers. Consumer health plans will not be able to improve value in the healthcare industry until the information becomes transparent and usable. This is why Porter calls this zero-sum.
I would direct you to the recent testimony given to congress in May by the Center for value-based insurance design which concludes that patients with higher cost sharing consume less of both high value and low value services since they can't determine the value difference in terms of their medical care needs which can lead to poorer overall health outcomes.
I think there is value in insurance design which encourages patient- ownership of their overall health. If this can be considered part of the consumer-driven trend, I support it.
http://www.sph.umich.edu/vbidcenter/pdfs/Chernew%20Testimony%2005-12-08%20_final.pdf
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Does our health system deliver value?
Comment from Should employers be responsible for health?
More winds of change? The CEO of a health plan contemplates the idea of a future without health plans on The Health Care Blog.
Understanding the research. A study shows that media coverage of medical research is overly excitable. According to the researchers, media stories do a poor job of clearly conveying either the limits of potential benefits or significance of potential harms. This was also written up on The Health Care Blog.
An interesting antidote to such coverage might be found on Britain’s National Health Service website section called Behind the Headlines. It summarizes news coverage, explains the bona fides of the researchers including funding sources and type of journal where research was published, and lists the all results of the paper not just talking points.
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Comment from Does our health system deliver value?
Great post. Generally I agree with the ideas except for the following:
"That is, competition to divide value rather than a competition to increase value. For example, when a patient is required to buy a consumer-driven health plan for which they have to pay a substantially higher percentage of the cost, that actually creates little value but shifts cost from the health plan and the employer to the consumer. That is zero-sum competition, not positive-sum or value-creating competition."
From my understanding, consumer-driven plans are primarily designed to reduce moral hazard, and by focusing consumer's attention on costs the system benefits by bringing prices down with a concomitant increase in value. Grant it, there is a redistribution of cost, but the desired effect is that there will be reduced waste, less demand-inducement, and more accountability leading to overall better healthcare.
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Does our health system deliver value?
Comment from Does our health system deliver value?
To learn more about Michael Porter’s work visit the website of the Institute for Strategy and Competitiveness at the Harvard Business School.
Find more about Redefining Health Care.
Watch Michael Porter or Elizabeth Teisberg talk about the book.
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Comment from How can we fund innovation?
Doctors generally agree that electronic medical records improve delivery of preventive medicine, help to reduce medication errors, and even improve clinical decisions, but only 17% of doctors in a nationwide survey report having access to them. See the full results from the study in the New England Journal of Medicine. Or read an overview of the research along with descriptions of efforts to expand access in an article from the New York Times.
One of the organizations mentioned as offering new solutions in electronic medical records, Athenahealth, is also discussed in Q3's article on how to fund innovation.
When is bad health good business?
The Wall Street Journal health blog highlights efforts to find investment opportunities arising from the obesity boom.
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Comment from Can health be a retail business?
One market innovation that brings customer service and price transparency to the fore is retail healthcare. In interviews with Q3, executives from MinuteClinic, one of the leaders in the field, described retails clinics, which are staffed by nurse practitioners, as a “disruptive” innovation that could free doctors to work at the top of their training. But the Wall Street Journal health blog reports on efforts by Illinois doctors to introduce restrictions on the retail clinics. The proposed state law hit a bump as the FTC found it too restrictive without offering consumers offsetting benefits.
The issue also flared up recently in Massachusetts, with Boston’s mayor expressing concern that the city’s efforts to ensure primary care for all would be harmed by the arrival of clinics in Walgreen’s stores in a Boston Globe article.
While the retail healthcare business model has seen growth from 125 total retail clinics three years ago to 963 as of last month, it is running into a rough patch. Plans to expand are being curtailed and some clinics are being closed, again according to the Wall Street Journal health blog.
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Comment from Should employers be responsible for health?
New York Times columnist Nicholas Kristof blogs that the aid work in poor countries fails too often because “it relies too much on benevolence and not enough on business.” He excerpts an article by Columbia University public health expert Josh Ruxin and cites statistics from Africa showing poor results because basic execution just isn’t happening.
Another Times columnist, Paul Krugman, points to data showing a sharp rise in the number of Americans who are underinsured. He also points out that that the discouraging numbers in the new report actually come from a period when the economy was expanding.
In the Washington Post, healthcare consultant Michael L. Millenson has an opinion piece about the obstacles to universal healthcare coverage in the U.S. He touches on everything from the stances of current candidates and special interest groups to Theodore Roosevelt’s 1912 promise to provide universal coverage to a YouTube video of a rap on healthcare coverage.
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Now that the Massachusetts healthcare plan has been in effect for over a year, the results are, well, mixed. The number of uninsured dropped nearly in half, but the costs have been higher than expected. And there are some early questions about whether there are enough providers to deliver healthcare to a more fully insured populace. Here are three different angles on the story:
A summary of the data from the Wall Street Journal’s Health Blog.
An opinion/analysis piece on Health Care Blog from a Stanford professor of medicine and a London School of Economics researcher that touches on what the Massachusetts experiment could show the country.
And a story about the growing need from primary healthcare in the New York Times.
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Comment from Can good health be good business?
As nonprofit organizations have increasingly been run more like businesses, questions are being raised about where to draw the tax-exempt line between for-profits and nonprofits. A New York Times story describes the shock waves reverberating through the not-for-profit world following a Minnesota Supreme Court decision that a small nonprofit daycare has to pay property taxes.
Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, takes up the issue on his blog and his readers react. Levy looks at what might be lost with the restriction of nonprofit status then considers “What do people hope to achieve by threatening to take away the tax-exempt status of current non-profits?”
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Comment from Can health be a retail business?
Google’s online personal health record recently became available to the public after a two month pilot project with patients of the Cleveland Clinic. Google’s entry is only the latest of many in a growing field that hopes to make electronic medical records available to all of a patient’s providers with the aim of better care with fewer errors. Google Health is starting with non-exclusive partnerships with more than two dozen companies and health organizations, including MinuteClinic, but hopes to grow to include “thousands of partners and millions of users.” Read the full New York Times story. Or analysis of what is significant about this move from David Kibbe, former director of IT at the American Academy of Family Physicians. Or find out more about the potential of electronic medical records in the Q3 discussion “How can we fund innovation?”
While the introduction of a health information innovation often attracts great buzz, that is only the start of a fairly predictable cycle that passes through disappointment before settling into a more realistic phase of integration and productivity. The “technology hype cycle” is highlighted by Robert...
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Comment from Would you rather be treated as a patient or a customer?
A week after my daughter had her baby, she collapsed at home with what turned out to be not one but two dissected carotid arteries. This was on a Friday evening, the start of hospital weekends. Nothing was moving. Fortunately my son-in law is an architect whose clients included several doctors and a hospital board member. Treatment from excellent doctors began as soon as he made several telephone calls to those blessed clients. What would have happened to her without these contacts?
She now has several excellent physicians for her on-going care, one of whom she passed on to me. This 40-something internist's frustration forced him to cut all ties to HMOs. "I have been unneutered, restored to my vigorous self. I can take care of patients rather than having to punt the ball all the time." He acts as if he has all the time in the world to speak to his patient, and even responds to e-mails. Is he treating me like a patient or a customer? Both, I believe.
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Barbara Chalsma SOM '82
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Would you rather be treated as a patient or a customer?
Comment from How can we fund innovation?
Healthcare experts explain what we should take away from studies that put administrative costs at 31% of healthcare spending or point to 100K deaths from hospital-acquired infections each year in the U.S. Read the interviews to better understand the numbers.
Around the web
The promise of technology facilitating a dramatic step forward in healthcare has been unfulfilled in part because of challenges from incompatible legacy systems and lack of incentives to make a change. Some of the opportunities for innovation discussed in Q3 are taking a small step forward with a pilot project in Boston bringing electronic medical records and pay-for-performance data capture options to 300 physicians in 175 offices. Read the story in Healthcare IT News.
Japan’s universal health care currently covers a population that has low rates of disease and high life expectancy, but the system will have to change according to a McKinsey report that finds advances in medical technology and growing demand for healthcare services from a wealthier, aging population will soon make financing the current system untenable. Several options are proposed in the report.
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Comment from Can good health be good business?
How do we get past fads and flops to develop a long-term healthcare strategy for the country? Check out the discussion at the 2008 Yale Healthcare Conference.
Around the web
David Wessel compares common ground in the McCain, Obama, and Clinton healthcare proposals in a Wall Street Journal op-ed and video commentary.
Wessel also points to a perspective piece in the New England Journal of Medicine that compares data on current public opinion about healthcare with numbers gather before the 1992 presidential election.
Pfizer CEO Jeffrey Kindler spoke at Yale about the uncertainty inherent in leading the world's largest pharmaceutical company. Read coverage or watch his comments.
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Comment from Can good health be good business?
(At the request of Q3 magazine, Mayumi Fukui commented on the connections between the interviewees for this article.)
I guess you could say that achieving good health is good business for all of us. It appears that my organization would be a potential customer for Marc, Mark, and Ephraim. I think we have some similar challenges in operating in very competitive, resource intensive, yet heavily regulated environments. I don't know if you'd call our interests at odds, but we do have review processes for adopting new technologies and therapies. And, in the same way that the University of Chicago Medical Center is an expense line for insurance companies and health benefit plans, the therapies and devices that Marc, Mark, and Ephraim are developing, would be expenses for us.
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Comment from How can we fund innovation?
Venture Capital and Healthcare: An Exchange
Three of the participants in "How can we fund innovation?" continued their conversation over email.
From: Zen Chu
Great topic. Healthcare is such a perfect example of the intersection of nonprofit, government, and business innovation and highlights the mission of SOM.
Here are some follow-up thoughts:
Good Medicine Is Good Business
-- Medicine is the ideal mission-driven business, but more than ever requires hard-edged business frameworks to analyze the tough tradeoffs.
-- Michael Porter demonstrates in his most recent book, Redefining Healthcare, that cost follows quality. Therefore, focusing on patient value and quality, not just of particular procedures, but across a broader patient-care cycle, ends up lowering costs.
-- In order to track quality, one must capture the data and organize it in a way to efficiently analyze it -- hence the huge opportunity in healthcare info technology and electronic medical records.
-- Because direct-to-consumer advertising has proven successful, more companies and institutions are focused on value to the patient as consumer, which will translate into more lifestyle medicine, for better or worse.
Fundamental Challenges
-- Many of the challenges in healthcare innovation result from three groups which are...
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Comment from How can we fund innovation?
A glossary of terms and companies referred to in the discussion.
Affymetrix: The developer of the GeneChip, a microarray that allows scientists to search for a particular gene in a DNA sample, and related software and tools.
Application Service Provider (ASP): A company that provides access to software applications over the internet, allowing organizations to outsource computerized functions. See Software as a Service.
Athena Healthcare: A company providing administrative and business services to medical practices over the internet.
biologic drugs: Broadly, a term referring to any drug based on living organisms. Often used to refer more specifically to drugs that mimic substances produced by the immune system.
biomarker: A distinctive biological indictor that can be used to assess a disease or some aspect of health; for example, the amount of a particular hormone or protein in the body.
BioTrove: The developer of the OpenArray SNP Genotyping System, a technology designed to search for variations in DNA. See SNP.
Cerner: A healthcare information technology company providing systems for managing patient records, billing, prescriptions, imaging, and other aspects of care.
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Comment from Can good health be good business?
The question of can good health be good business prompted this email exchange among members of the Class of '87.
Eric Oliner '87
January 14, 2008
My business, Hammes Company, is entirely focused on making "good health be good business" for all of our healthcare clients. We advise them through strategic and operational planning, project management, financing, realty advisory services, and ownership opportunities.
The healthcare industry is vast, rapidly evolving, heavily regulated, and for the most part, nonprofit. My appreciation for the dedication and daily sacrifices made by caregivers, the commitment to providing care to the indigent and uninsured by hospitals, and the challenges those institutions face, motivates me as a consultant/developer to truly act as their agents, to help them find solutions that are simultaneously good for patients and good for the bottom line that allow them to provide first-class healthcare services.
As a healthcare consumer, I want to be treated both as a customer and a patient. I want a patient- and family-friendly physical environment, a system that treats me as a unique individual, that respects my privacy and dignity, that efficiently provides me with the best possible care, with state-of-the-art technology and well-trained professionals...
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Comment from How far would you go for surgery?
The medical tourism industry grows practically every day. Keeping up with emerging global healthcare practices can be daunting. Below are a series of links that illustrate different aspects of this worldwide phenomenon.
Author Jeff Schult’s website: http://www.beautyfromafar.com
International non-profit consortium of doctors and hospitals promoting medical tourism: http://www.medicaltravelauthority.com
Dubai Healthcare City: http://www.dhcc.ae
For-profit medical tourism group: http://www.cmiregistration.com
Study by conservative think tank on benefits of medical tourism: http://www.ncpa.org/sub/dpd/index.php?Article_ID=15207
News report on a government study tracking the booming medical tourism industry in India: http://timesofindia.indiatimes.com/Medical_tourism_booming_in_India/articleshow/2924252.cms
Medical tourism blog: http://treatmentabroad.blogspot.com
World Bank study on medical tourism: http://www-wds.worldbank.org
BlueCross BlueShield of South Carolina announces medical tourism initiative: http://www.southcarolinablues.com/bcbs/bcbs_Memb1.nsf/comp
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Comment from What is the return on a life saved?
Here are some additional sources of information about the work of Ed Kaplan and David Paltiel:
A profile of Kaplan
Ed Kaplan’s Yale SOM profile page
David Paltiel’s Yale School of Public Health Profile page
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Comment from Listening to patients and staff
Additional comments on creating and managing change in a healthcare setting from Zeev Neuwirth, a physician and the vice president of clinical effectiveness and physician affairs for Atrius Health, a nonprofit alliance of five medical groups in Massachusetts. Harvard Vanguard Medical Associates, the largest of Atrius Health’s groups, has a pilot program funded with a grant from Blue Cross Blue Shield to overhaul how it delivers healthcare.
On management approach
My firm belief is that there is no technology, no electronic medical record system, and no process improvement approach that’s going to create a safe, effective, and efficient healthcare delivery system without us also taking a social perspective — that is, without the integrated social engagement of the people involved in healthcare delivery. Healthcare is as much a social and communal process as it is technical. I think that anthropology, sociology, and community organizing have as much to teach us as does continuous quality improvement and quantitative population health techniques. Leaders in healthcare all over the country don’t seem to understand this — really smart people. There seems to be this belief that technology, quantitative metrics, standardization, and resource allocation are going to solve our healthcare problems. It’s clearly...
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Listening to patients and staff
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Below are links to selected papers by the participants in “How do healthcare consumers make decisions?” including some of the research mentioned during the conversation.
Erica Dawson (with K. Savitsky and D. Dunning)
"Don’t Tell Me, I Don’t Want to Know: Understanding People’s Reluctance to Obtain Medical Diagnostic Information"
http://www.mba.yale.edu/faculty/PDF/DiagnosticTesting.pdf
Peter Salovey (with P. Williams-Piehota, J. Pizarro, T.R. Schneider, and L. Mowad)
“Matching health messages to monitor-blunter coping styles to motivate screening mammography”
http://research.yale.edu/heblab/heblab-yale/myweb.php?hls=10085
Keith Chen (with F. Lange)
"Education and Allocative Efficiency: Evidence from Breast Cancer Screening"
http://web.econ.uic.edu/health/health.09122007.pdf
Lynn E. Sullivan (with F. Altice, D. Smith-Rohrberg,S. Basu, S. Stancliff, and L. Eldred)
“The Potential Role of Buprenorphine in the Treatment of Opioid Dependence in HIV-Infected Individuals and in HIV Infection Prevention”
http://www.journals.uchicago.edu/doi/pdf/10.1086/508181
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Field Studies in Healthcare
Michael Apkon has several times taught a class called Field Studies in Healthcare, which allows students from Yale SOM, the School of Public Health, and other parts of the university to take on consulting projects for healthcare organizations around New Haven. Some of their clients over the years have included an AIDS hospice, a visiting nurse service, Yale University Health Services, as well as numerous departments within Yale-New Haven Hospital (YNHH).
Howard Forman, who has co-taught the course with Michael Apkon, explains, "It's an extraordinary opportunity for organizations to see into areas where they might not have the resources to bring in a private consultant."
"Healthcare is a very different animal," Forman says. "And this class offers the opportunity to see in real life why healthcare is so different and so difficult." He adds, "Without having to take several classes, students are able to understand the issues around healthcare operations, finance, and competitive strategy."
Several of the students who have taken Field Studies in Healthcare spoke with Q(n) magazine about the experience:
Jonathan Swersey '05 worked on diagnostic imaging capacity issues in the emergency department at YNHH. "We worked on...
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Eliminating medical errors
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Healthcare Reform in Pennsylvania
A Commentary By Professors Theodore R. Marmor and Jerry L. Mashaw
"Pennsylvania health-care reform a solid, cost-aware plan"
Theodore R. Marmor and Jerry L. Mashaw
Published in the Philadelphia Inquirer on March 31, 2008
Read the op-ed in its original context on the Philadelphia Inquirer website.
Continued gridlock in Washington over health-care reform is forcing more and more states to devise their own plans in an effort to cover the uninsured, the underinsured, and to fight increased costs on several fronts.
Massachusetts recently launched an ambitious program that is being closely watched as a possible model. Efforts to provide universal coverage to the uninsured in California failed.
Now, along comes Pennsylvania, home to 800,000 uninsured residents. Gov. Rendell has put forward a responsible plan and House lawmakers passed a scaled back version on March 17 that Rendell seems inclined to support.
What has Rendell and his legislative colleagues proposed where others have struggled to find a workable solution?
First, consider that there are really only two major ways to reform health insurance responsibly and Pennsylvania has taken one of them. A state or...
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Should employers be responsible for health?
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For more on the Massachusetts Health Plan
Two years after healthcare reform legislation made it mandatory for nearly every Massachusetts resident to have health insurance the pros and cons of the program are still up for debate. Here are some resources for learning more.
MIT economist Jonathan Gruber was an advisor to the state in designing the program. His 2006 essay gives an overview of the planning and early stages of implementation.
A 2008 newsletter article from the Health Section Council of the Society of Actuaries offers explanation and commentary.
Here is a summary of the legislation and two progress reports. One report comes from the Health Connector, an independent state agency created to administer the program, and the other report comes from the Massachusetts Division of Health Care Finance and Policy.
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Comment from Can good health be good business?
I have interacted with the healthcare system as patient, close observer, and industry insider. Like most, I believe it has its faults, one of which I'd like to explore through the experiences I recount below. Each of the three anecdotes indicates, albeit from a data point of one, that a short term focus limits the healthcare system's ability to truly address health, and consequently, reign in rampant costs.
1. It was two years ago, as I prepared to launch my own business, and took time off to that end, that I explored an individual health insurance policy. Calling several companies led me to a tenable quote of $200 per month for decent coverage, of course provided I had a good health record. At the time, I was six months removed from completing the L.A. marathon, and three months prior had finished my first half Ironman. My training included meticulous nutrition, vigorous exercise, and abundant sleep. I was, in short, the picture of health, with no pre-existing conditions -- a shoe-in for the "healthy individual" policy. As I completed my form, I included an MRI that examined my knee for an injury following my marathon (it revealed a bruised bone...
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Aydrian Drewery '98
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Can good health be good business?
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Good health is certainly good for business. My team's business is making investments into private equity and venture capital funds as well as directly into portfolio companies. Healthcare investing is one of our focus areas and we look to make investments ranging from buyout investments to growth and venture investments. The healthcare space is compelling because it is supported by very strong demographic trends, strong consumer discretionary and non-discretionary spend trends, and in most cases compelling barriers to entry such as clear patent protection.
In addition, it is more recession-proof than other spaces and in many cases countercyclical to our other investment areas, which are great attributes when viewed on a portfolio basis. By making investments in the healthcare space, we put risk capital to work that seeks to find solutions for consumers, both society and business, that provide a better quality of life while making an appropriate rate of return for the risk undertaken.
In many cases our investments also streamline businesses in the healthcare space so that they are more efficient and effective, which is a benefit to business. This resultant better quality of life from healthcare investing should generally be accretive to business...
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Peter T. Martenson '00
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Can good health be good business?
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Clearly, healthcare is big business -- the industry is so large that it is often expressed as a percentage of GDP. Healthcare will continuously struggle with how much we want to move to a free market system (where the higher quality services will migrate away from the poor and to those best able to afford them), versus a system of universal healthcare, where we subsidize those who cannot afford to pay. Right now, we seem to be moving as a nation towards universal coverage.
Under any universal coverage plan, however, costs will skyrocket, as there will be tremendous incentive to innovate treatments when there is a built-in payer. Prices of new therapies are largely monopolistic due to patent protection. Insurance companies may require many steps to be taken before trying the newer, more expensive therapies, but they are unlikely to deny them outright, as people are not agreeable to the idea of partial coverage. This, combined with the aging population creating demand, will likely keep healthcare costs rising.
Cost increases will be partially mitigated by correcting inefficiencies in healthcare, but politically there will be a strong desire to force price cuts through regulation. Pharma will likely be the...
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Michael Howes '01
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Can good health be good business?
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I serve as the vice president and general manager of the Defense and Industrial Division of STERIS Corporation, an NYSE biomedical company providing global solutions for infection prevention. The mission of my division has been to introduce an entirely new method of controlling infectious diseases called Advanced Room Sterilization (ARS). Our adversaries in the microbial world range from the common cold to the so-called Super Bugs -- staph (MRSA), C. diff, antibiotic resistant TB, anthrax, etc. Our goal is to add an entirely new weapon to our war on germs: the ability to eliminate them from the environments where we live, work, get cared for, and play.
The news for us humans from the germ wars is not good. The bugs are getting smarter and evolving faster than our ability to generate new vaccines and antibiotics. And the costs are staggering: 90,000 lives lost per year to hospital acquired infections in the U.S. alone at a cost variously estimated between $5 billion and $10 billion. Beyond these estimates of mortality and direct financial loss, the collateral impacts in business disruption and personal suffering are immense. Hospital Acquired Infections (HAIs) have now been joined by Community Acquired Infections (CAIs) so...
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Matt Walton '78
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Can good health be good business?
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I believe good health and good business are strongly related in several ways.
First, disciplined healthcare businesses are crucial for creating good health outcomes. For the past two years, I have been CIO for MinuteClinic, the company that pioneered high-quality, convenient, low-cost healthcare delivered in a retail setting. We have a disciplined business model that rethinks long-accepted flaws in healthcare: We post prices outside our clinics, we use technology and business processes to drive evidence-based medicine, and we are creating a national brand for reliable, quality care. Forbes magazine recently listed MinuteClinic as one of the top ten disruptive innovations of the last decade because of the ways we bring business innovation to healthcare.
It's also obvious that good health is key to business health. Healthcare costs are crippling U.S. businesses, especially those that face competition from other nations without such heavy health costs.
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Cris Ross '88
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Can good health be good business?
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Can good health be good business? Definitely, and I would add that we should look not just at bodily functions, but also mental health. They are linked more than the old mind/body questions would presume and we are learning that. I think a key is education and there isn't enough of it and it is often incomplete or misinformed. The management of any disease, chronic or not, as well as an understanding of our complete responses--bodily, emotionally, mentally--are critical to day-to-day living and productivity. We know the health of every person on this earth is critical to the well-being of nations and economies. I don't advocate being healthy for the sake of the bottom line, but all dimensions of life including business do flourish if a healthy condition is maximized--anywhere at any economic level.
A tangential thought (that bridges economics, legal definitions, historical perspective, and identity) is that a corporation in this country is endowed with the rights of the individual, but it is also a "body" and its health can be measured and managed. I won't push the analogy because it obviously fails after several steps, but it is no accident.
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Rudy Hokanson '81
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Can good health be good business?
Comment from Would you rather be treated as a patient or a customer?
I prefer to be treated as a patient -- the last thing in my doctor's mind should be their paycheck or how he/she can best endeavor to upsell. I trust medical professionals to provide their educated opinion regarding my care as a whole person, neither viewing me as a mere set of symptoms nor as the amount of money they can expect to receive as the result of my visit.
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Jason Kroon
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Would you rather be treated as a patient or a customer?
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I'd want the hospitality normally provided to customers, but the objectivity owed a patient.
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Gene-Fu Liu YSM '09
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Would you rather be treated as a patient or a customer?
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A patient, since I expect more than a product/service. I expect empathy/compassion/understanding, none of which I want or expect as a customer.
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Adam Licurse YSM '09
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Would you rather be treated as a patient or a customer?
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As a patient because I think of my doctor as someone who cares and not someone I'm buying something from.
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Leon Boudourakis YSM '08
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Would you rather be treated as a patient or a customer?
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Hmm. What exactly is the difference between a customer and a patient?
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Dina Mayzlin
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Would you rather be treated as a patient or a customer?
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I am happy that we essentially have our health and are well insured. This has not been the case every year since graduating from SOM. Because we are well covered, Deborah was able to and finally had surgery on her neck to attempt to relieve pain from a car accident five years ago. Ask me in October how the third recession we have experienced since '91 is treating me!
A patient is a customer. Simple as that. And we own our data. And our ability to choose should be facilitated. And key barriers prevent many market forces from improving service and quality. After trying many docs, we finally found good service. The surgery and recovery was priced at many tens of thousands. I can only wonder how much of that pricing is caused by our byzantine system and how much really reflects the cost of service delivered.
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John Steinert '93
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Would you rather be treated as a patient or a customer?
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I disagree with the premise that these must be opposed ideas. At MinuteClinic, we treat patients as customers with ideas that come from retail: posted prices, service and convenience desired by customers, and a national brand that consumers can trust. But we also remain committed to patient safety and quality, as indicated by things like our accreditation by the Joint Commission. We have published clinical results that show our combination of business execution and clinical discipline can lead both to superior patient outcomes and customer satisfaction.
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Cris Ross '88
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Would you rather be treated as a patient or a customer?
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A customer or a patient? Neither. I want to be treated like a human being who has human needs. Qualities like kindness, attentive care, being up-to-date on medical knowledge pertaining to common medical conditions and medications used to treat them, e.g., hypertension, cholesterol problems, arthritis, and the ego strength to know when to consult with or refer to other doctors when they are unsure of treatment related to a patient's medical problems.
My health insurance is through Medicare. I am deeply concerned about its future solvency. I am a regular reader of two newspapers, magazines, listen to two news stations a great deal, and am a member of AARP. However, I hear nothing about the nature and degree of its solvency and proposals to "fix" the problem. All of the presidential candidates talk of the need to reform our healthcare system, but I have not heard how they see this affecting the elderly. I realize that most SOM graduates are not old enough to be eligible for Medicare benefits and/or they are wealthy enough that they will not have to worry about paying for their healthcare.
Regrettably, a chronic medical condition forced me to retire early and Medicare...
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Phyllis Siersma '82
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Would you rather be treated as a patient or a customer?
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In August of 2003, I had a total hip replacement at a major Manhattan hospital specializing in these sorts of things.
On the day after my surgery, a very elderly gentleman who apparently had had a major surgery was brought in and placed in the other bed in my room. His family, apparently from out of town, went to the trouble and added expense of hiring for him a private nurse. In the evening, this man began experiencing increasing discomfort and asking his nurse for additional medication. She replied that he already had been given his prescribed painkillers and that he should just try to go to sleep. As he continued to complain, she steadfastly refused to speak to anyone about doing anything for this man, despite the growing intensity of his expressions of pain as well as my own urging that she try to get in touch with his medical team.
Finally, I pushed my own call button to summon a nurse, to whom I explained the situation and she left, promising to "speak to someone."
As the evening wore on, not only did no one respond, but this man's discomfort turned to what...
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Stewart Halpern '82
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Would you rather be treated as a patient or a customer?
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I would rather be treated as a patient because I believe when patients are viewed as customers, the private sector attempts to capitalize on the healthcare industry and thus raise the cost of healthcare.
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Jasmin Jose '08
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Would you rather be treated as a patient or a customer?
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I would rather be treated as a customer since the merchants (e.g. hospitals, physicians, HMOs) will treat me as an informed consumer with choices and attempt to lure me by offering great services and options. When I go to a grocery store, I expect the freshest fruits to be available. If the quality of fruits is low, then I will shop somewhere else. Moreover, there are financial incentives to improve operations within the provider system, which will result in increasing competition within the industry for patients.
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Sophia Young EPH '08
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Would you rather be treated as a patient or a customer?
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I have been practicing internal medicine for nearly 15 years in Oregon. When I graduated from SOM in the early 1980s I immediately went to work for a large international bank based in New York City. It was a great job and I traveled around the world. However, when I moved to Oregon several years later to start a family and settle down, I took stock in my career. I decided to go into medicine because I started to realize that I would be happier selling health to individuals rather than trying to continue selling commercial banking products.
My patients are "customers." In my years of practice I have come to believe that patients are not only interested in their own health but also that they actually become more committed to a healthcare plan when they are involved in decision-making. Many of my patients are well-educated and can make informed decisions about their healthcare choices when presented with evidence-based medicine. They are certainly customers, whether dealing with a chronic disease like diabetes or deciding when and where to have knee replacement surgery. This is good for making some medical decisions, and may introduce competition and efficiency into healthcare decisions....
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Ellen Mayock '81, MD
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Would you rather be treated as a patient or a customer?
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The question of health is central to so many things. Regardless of the nuances or philosophical underpinnings, I will always hear my mother saying "As long as you have your health..." It was not "money" or even "love" but rather "health." Of course, when I discovered I had type 1 diabetes in my mid-20s, I wondered if that was it! Well, luckily -- not so. However, as life goes on, our perspectives on health increase as we learn we are not invincible.
Being someone with a chronic disease, I have learned to be thankful that I have enough resources to seek out knowledgeable and personal care that addresses my needs and helps me manage my condition. I would like to be treated as a customer rather than a patient when I am coherent and conscious -- meaning when I can make choices and when I can absorb and understand my options in treatment. I want to be interactive with my healthcare providers. I want to take ownership of my condition. To some healthcare professionals, a patient is an equal partner. That is what I want. I don't want to be told what to do and sent out the door...
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Rudy Hokanson '81
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Would you rather be treated as a patient or a customer?
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The "Would you rather be treated as a patient or a customer?" question is both multi-dimensional, and also changing around the issue of infectious disease. Awareness of the prevalence of HAIs is growing thanks to a recent announcements by the Centers for Disease Control and Prevention (CDC) and frequent articles in international media detailing the scope and severity of the problem. With standardized reporting of HAIs now mandatory in many states, quantitative measurement of the incidence of infectious disease at the individual hospital level is becoming possible. Without such data, HAIs have been perceived by an uneasy public as a general threat. With data available at the individual hospital level, prospective patients will be able to exercise choice in determining where they wish to receive healthcare based in part on their perception of the relative cleanliness of the facilities within their vicinity.
Choice makes people customers. It permits them to ask tough questions, and direct their business towards those institutions that provide satisfactory answers. And interestingly, this same principle holds true not only for the traditional consumers of healthcare -- "patients" -- but also for healthcare workers as a new class of "customers" themselves. Healthcare workers are the front...
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Matt Walton '78
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Would you rather be treated as a patient or a customer?
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The fact that the question of whether one should be treated as a patient or as a client by the healthcare system represents the fundamental flaw of medicine in the United States. In my opinion, health care is a fundamental right that should be afforded to every human being, and, therefore, we should all be treated as patients. To treat a patient as a client suggests that health care is a business where profit and financial gain is the goal of what we do. As physicians, our first responsibility is to improve the health of our patient, rather than to satisfy a client and make a profit.
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Zosia Piotrowska YSM '08
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My health is not a luxury, nor is it a commodity to be bought and sold. I want to be treated as a human being with a deep physical, and therefore emotional and spiritual need. If that makes me a customer, then great. Otherwise, I'd rather be considered a patient.
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Gregory Nelson YSM '08
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Would you rather be treated as a patient or a customer?
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I would much rather be treated as a patient than a customer. As a future doctor I also plan to treat people as patients rather than customers, because I believe that healthcare is a right and not a commodity. If healthcare is a commodity then the world's rich can buy the best goods and the world's poor can't buy much of anything, and ultimately I think we all suffer in such a system where only the rich have access to healthcare. I just recently had the privilege of hearing Paul Farmer speak. He is a strong advocate for healthcare as a right, but also talks about "public good for public health," which he describes as not as good as healthcare as a right, but a step in the right direction. What he means by "public good for public health" is that we all benefit when there is healthcare for all and we all suffer when there is not. An obvious example of this is infectious disease--if one person has it because they can't afford treatment, or develops resistant disease because they can't afford to take medication regularly, then the public also suffers, not only because...
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Libby Houle YSM '08
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Would you rather be treated as a patient or a customer?
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I would rather be treated as a patient. I want a medical provider to consider my best interests and offer me a high standard of care, without regard to my ability or desire to pay for their services. Treating me as a customer implies that basic preventive services are optional investments that I must weigh against alternative uses of my money and time, as opposed to prerequisites for living a healthy and productive life.
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Rachel Wattier YSM '09
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Of course, as a patient, I would want the unflagging dedication of my physician to order any expensive test or any expensive medication, which I do not pay an additional cost for. But, as a concerned physician, I recognize that irrational use of care leads to a society which then has to ration care for those members who cannot afford care, leading to a greater problem of the uninsured.
When I attended SOM, I had the good fortune of learning from faculty members William Kissick and Ted Marmor, whose academic works serve to shed light on the larger looming question of the gaps in the American healthcare system. As Professor Kissick points out, the medical community has two cultures: patient care and business practice. The physician would like to employ unlimited resources for the patient, without regard to overall cost. The hospital CEO must be concerned about cost, viewing the same patient as a customer who provides a certain amount of dollars to the hospital, gets a certain amount of care, and has a certain associated cost of care. In the aggregate, the hospital CEO needs to see a yearly profit. Above these microeconomic constraints, Professor Marmor has outlined...
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Glen Gechlik MD, SOM '05
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Healthcare is a broad category, so I would like to mainly focus on two segments: anti-aging and pet-care. Both of these segments are rapidly growing in Japan. The stock prices for the pet-care industry especially reached their highest level last year. I believe investing in these two segments will yield high returns. As Japan is experiencing the lowest birthrate and progressive aging, anti-aging healthcare products are well-sold and advertised. For the same reason, people here want to have a pet as a substitute for a child. This is best exemplified by the setup of a pet-insurance scheme. Since we have an only child, we have a dog, too. She (a female dog) is now 12 years old. Veterinarians have high incomes and they charge a small fortune. We probably have spent as much money as for a BMW. In sum, selective investment in healthcare is important. I just think that the aforementioned two segments will grow rapidly in Japan.
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