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The Important Role of Faith-based Organizations in the Context of COVID-19

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Kathryn Derose
Michael Mata

By KATHRYN P. DEROSE and REV. MICHAEL A. MATA

As Christians experienced Holy Week 2020, the week commemorating the trial, suffering, and death of Jesus, the somber tone such remembrances evoke took on new meaning in the midst of the COVID-19 epidemic with the catastrophic loss of life and livelihoods. Many churches remained physically closed, some already outfitted with sophisticated systems for live streaming and others scrambled, along with their congregants, to create meaningful virtual worship and fellowship opportunities. Finding ways to maintain physical distancing while still providing social and spiritual connections.

These challenges face people of other faiths as well since the current guidance regarding social distancing affected those observing Passover, April 8-16 and will likely affect Orthodox Easter, April 19 and Ramadan, which will start April 23.

Maintaining social and spiritual connections in the midst of COVID-19 are not the only challenges facing our communities of faith. For centuries if not longer, religious congregations have played critical roles in providing and supporting social services within communities. There are over 345,000 religious congregations in the US of various faiths and denominations and, despite declining rates of religious affiliation and attendance, national surveys still find a sizeable proportion – about 45% – of all adults report attending religious services at least monthly. Religious congregations play even more important roles in particular subgroups, such as low-income communities and among certain racial-ethnic minority groups and immigrants, the elderly, and other vulnerable groups, making faith-based organizations critical to the COVID-19 response in the short and long terms.

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Concrete Problems: Experts Caution on Construction of Digital Health Superhighway

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By MICHAEL MILLENSON

If you’re used to health tech meetings filled with go-go entrepreneurs and the investors who love them, a conference of academic technology experts can be jarring.

Speakers repeatedly pointed to portions of the digital health superhighway that sorely need more concrete – in this case, concrete knowledge. One researcher even used the word “humility.”

The gathering was the annual symposium of the American Medical Informatics Association (AMIA). AMIA’s founders were pioneers. Witness the physician featured in a Wall Street Journal story detailing his use of “advanced machines [in] helping diagnose illness” – way back in 1959.

That history should provide a sobering perspective on the distinction between inevitable and imminent (a difference at least as important to investors as intellectuals), even on hot-button topics such as new data uses involving the electronic health record (EHR). 

I’ve been one of the optimists. Earlier this year, my colleague Adrian Gropper and I wrote about pending federal regulations requiring providers to give patients access to their medical record in a format usable by mobile apps. This, we said, could “decisively disrupt medicine’s clinical and economic power structure.”

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Click and Exercise! Amazon, Netflix, Hulu—Are You Listening?

By DEBORAH A. COHEN

Physical inactivity is a mounting challenge for America. In reviewing the 2013-2015 American time use survey, we found that most Americans report spending their daily leisure time watching screens, and devote only a small fraction of leisure time—24 minutes for men and 14 minutes for women—to physical activity. A recent longitudinal examination of the National Health and Nutrition Examination Survey showed that sitting time increased by an hour a day between 2007 and 2016, with the largest increases among adolescents ages 12-19 and adults, 20 years and older. As mortality rates for heart disease have begun to climb, increases in sedentary behavior bodes poorly for future control of disease and health care costs.

The explosion in streaming apps and content is likely contributing to the increased sitting time. According to the Motion Picture Association of America, TV and movie views have more then doubled between 2014 and 2018. The availability of multiple series and the ability to binge watch can keep people glued to their couches for hours at a time. The immersive quality of the programming makes it increasingly difficult for viewers to pull themselves away from their screens. Yet, the technology could provide options to help viewers watch and still get regular physical activity.

Currently, after each episode, an option is available to allow the viewer to immediately call up the next episode. Why not consider adding a pop-up that can remind viewers that sitting more than 20-30 minutes at a time may not be good for health, and that it’s important to move around to avoid chronic diseases? A narrator could ask viewers to treat themselves to an activity break. Then the viewers could have the option to choose a short video that can guide them through a 10- minute exercise break. Or even a 5-minute break. Something is better than nothing.

There could be many options, from a just a simple stand up and stretch, like the 7th inning break at a baseball game, to vigorous workouts, like the 7-minute workout published by the American College of Sports Medicine or doing a Bhangra dance with a Bollywood film star. 

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The Little Exchange that Could…Transform the U.S. Health Care System

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By ROBERT S. RUDIN and JAYME FUGLESTEN

flying cadeuciiWhat do the classic children’s’ book “The Little Engine that Could” and federal investment in health information exchanges have in common? More than you’d think.

Much has been said about the fragmentation of the U.S. health care system and how this fragmentation can result in higher costs and worse outcomes for patients. Health Information Exchanges (HIEs) – organizations that facilitate the secure sharing of health information – are one effort to improve communication among providers, better coordinate care, boost patient satisfaction, and reduce health care costs.

To spur these exchanges the federal government has invested nearly $600 million to support the development of statewide HIEs. But, what has been the return on this investment and are the results worth the expense? This month, Sens. Lamar Alexander, Richard Burr, and Mike Enzi asked the Government Accountability Office to examine that very question.

The senators’ goal to learn more about what the government received in return for its investment is certainly a worthy one, but it is a difficult question to answer. To date, there has been very little research on the effect of HIEs on health outcomes, costs, or patient and provider attitudes toward HIEs. In fact, according to a recent RAND review of the existing research supporting the efficacy of HIEs, very few of the more than 100 existing operational HIEs have been evaluated. Without evaluation, it’s difficult to draw conclusions about what works and what doesn’t and to ensure that any future investment on the part of federal or state government is made wisely. By not building evaluation into this program, we’re missing opportunities to improve the health care system by learning from experience.

Here’s an analogy that is useful in thinking about federal investment in HIEs. Imagine that 150 years ago, the United States decided to build a national rail network to connect all major U.S. cities at an estimated total cost of $60 billion (in today’s dollars). What if five years into the effort $600 million had been spent to build portions of the tracks between Chicago and Pittsburgh, New York and Boston, and Washington and Philadelphia?

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Circulation: The Nineties Called. They Want Their Wellness Policy Back

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By AL LEWIS and VIK KHANNA 

flying cadeuciiLast year, we soundly criticized the American Heart Association (AHA) on this blog for its proposal to lower the thresholds for treating cholesterol and getting larger numbers of Americans to swallow statins. We also exposed wellness vendor StayWell, for its mathematically impossible claims of success in British Petroleum’s wellness program. Proving that great minds aren’t the only ones that think alike, StayWell and the AHA have now joined forces.  Specifically, the AHA invited the CEO of StayWell, Paul Terry, Ph.D., to help write its workplace wellness policy statement, sort of like Enron inviting Bernie Madoff to help design its financial plan. You don’t learn of this fox-in-the-henhouse conflict of interest unless you read the table on the penultimate page of text.

Naturally, Mr. Terry parlayed this windfall to StayWell’s advantage. The statement: “currently available studies indicate that employers can achieve a positive ROI through wellness” is footnoted to two studies authored by:  Paul Terry, along with other Staywell executives.  One wonders how a StayWell executive writing policy for the AHA based partly on StayWell’s own articles passes the AHA’s own test of “making every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship.”

How did this conflict of interest get by the peer reviewers? Look at the list of peer reviewers. Prominent among them is Ron Goetzel. Readers of THCB may recall Mr. Goetzel not just from his central role in the Penn State debacle, but also from the ”The Strange Case of the C. Everett Koop Award,” in which it was documented that his committee gave the ironically named award to a sponsor of the award (without disclosing that conflict), even though that sponsor had admitted lying about saving the lives of 514 cancer victims, who, as luck would have it, didn’t have cancer. (The sponsor, Health Fitness Corporation, a division of the equally ironically named Trustmark, has won the Koop award several times, thus proving the cost-effectiveness of their sponsorship.)

If this litany were not enough to dismiss the policy statement forthwith, there is small matter of the actual policy itself, a full employment act for wellness vendors and cardiologists alike, advocating more screening of more employees more often, while ignoring more self-evident facts than Sergeant Schultz. Specifically, they cherry-picked the available literature, continuing to cite the old “Harvard study” whose lead author has now walked it back three times. Except that they didn’t call it the “old Harvard study,” but rather a “recent [italics ours] meta-analysis,” despite the fact it was submitted for publication in 2009, and the average year of the analyses in the study was 2004.  Some studies began in the 1990s and were able to use sleight-of-hand to “show savings” despite presumably — in accordance with the conventional wisdom of the era — getting people to eat more carbohydrates and less fat.  No wonder Soeren Mattke of RAND Corporation dismissed the Harvard data as archaic in his interview with CoHealth radio in February 2014.

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The Misuse of Meaningful Use, Part II

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By HAYWARD ZWERLING, MD

flying cadeuciiAs a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts

In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.

As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.

Recently, The Office of the National Coordinator for Health Information Technology (HHS)  asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities”

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Socialized or Not, We Can Learn from the VA

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By ART KELLERMANN, MD

Art Kellerman RAND optimizedIn a post on the New York Times’ Economix blog not long ago, Princeton economics professor Uwe E. Reinhardt addresses the common characterization of the British health care system as “socialized medicine.” The label is most often used pejoratively in the United States to suggest that if anything resembling Great Britain’s National Health System (NHS) were adopted in the U.S., it would invariably deliver low-quality health care and produce poor health outcomes.

Ironically, Reinhardt notes, the U.S. already has a close cousin to the NHS within our borders. It’s the national network of VA Hospitals, clinics and skilled nursing facilities operated by our Veterans Healthcare Administration, part of the Department of Veterans Affairs. By almost every measure, the VA is recognized as delivering consistently high-quality care to its patients.

Among the evidence Reinhardt cites is an “eye-opening” (his words) 2004 RAND study from in the Annals of Internal Medicine that examined the quality of VA care, comparing the medical records of VA patients with a national sample and evaluating how effectively health care is delivered to each group (see a summary of that study).

RAND’s study, led by Dr. Steven Asch, found that the VA system delivered higher-quality care than the national sample of private hospitals on all measures except acute care (on which the two samples performed comparably). In nearly every other respect, VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.

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10 Ways Innovation Could Help Cure the U.S. Health Spending Problem

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By Steven Garber

flying cadeuciiThe United States spends more than $2 trillion per year on health care, surpassing all other countries in per capita terms and as a percentage of gross domestic product.

New, expensive medical technologies are a leading driver of ballooning U.S. health care spending. While many new drugs and devices are worthwhile because they substantially extend lives and reduce suffering, many others provide little or no health benefit.

Many studies grapple with how to control spending by considering changing how existing technologies are used. But what if the problem could be attacked at its root by changing which drugs and devices are invented in the first place?

Recently, my colleagues and I explored how medical product innovation could be redirected to reduce spending with little, if any, sacrifice to health and to ensure that any spending increases are justified by sufficient health benefits.

The basic approach is to use “carrots and sticks” to alter financial incentives for drug and device companies, their investors, health care payers and providers, and patients.

The ten policy options below could change which technologies are invented and how they’re used. In turn, this could cut spending or increase the value (health benefits per dollar spent) derived from new products that do increase spending.

We urge policymakers—both public and private—to consider these options soon and to implement those that are most promising. Policymakers should also consider how to reduce spending and get more value from health services that don’t involve drugs or devices.

The longer the delay, the more money will be badly spent.

1. Encourage Creativity in Funding Basic Science

The National Institutes of Health (NIH), the leading funder of basic biomedical research, typically favors low-risk projects. Funded researchers who fail to achieve their goals are much less likely to secure additional NIH funding. Encouraging more creativity and risk-taking could increase major breakthroughs.

2. Reward Inventors with Prizes

Public entities, private health care systems, the philanthropic sector, or public-private partnerships could award prizes to the first to invent drugs or devices that satisfy certain performance criteria, including a potential to decrease spending. Winners could receive a share of future savings that their product brings the Medicare program, which spends more than $500 billion annually.

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How to Avert a Doctor Shortage

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By MICHAEL D. RICH

Anticipating a growing, aging population and the anticipated demands of those newly insured under the Affordable Care Act, the Association of American Medical Colleges estimates that the United States will face a shortage of 130,000 physicians just over a decade from now.

This projected shortage, which also has been recognized by the federal government and some academics, could mean limited access to care for many Americans, plus longer wait times and shorter office visits for those who do find a doctor.

But like treating an illness, heading off the doctor shortage could hinge on early detection and intervention. And as research at RAND and elsewhere has shown, the treatment options should go beyond the standard prescriptions of training more doctors or reducing care for patients.

A RAND analysis issued last fall concluded that increased use of new models of medical care could avert the forecasted doctor shortage. These models would expand the roles of nurse practitioners, physician assistants, and other non-doctors.

One option is “medical homes,” which are primary care practices in which a personal physician leads a team of others — advanced practice nurses, physician assistants, pharmacists, nutritionists — in overseeing the delivery of individuals’ health care needs, roughly comparable to a dentist overseeing hygienists. By drawing on a broader mix of health care providers, this team approach lessens reliance on the physicians themselves.

Medical homes currently account for about 15 percent of primary care nationally. Research on their efficacy is continuing. A RAND report released in February found mixed results for a major pilot effort of the new model and offered suggestions for improvement. Still, if medical homes continue to gain traction and grow to nearly half of primary care, the nation’s projected physician shortage could shrink by 25 percent.

Another approach is nurse-managed health centers, which are clinics managed and operated by nurses who provide primary care and some specialty services. They are typically affiliated with academic health centers, but operate without physicians. If nurse-managed health centers were to account for 5 percent of primary care, up from just 0.5 percent today, the anticipated doctor shortage could, again, fall by 25 percent.

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Checking the ACA’s Vital Signs

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By Evan Saltzman

Despite pervasive challenges associated with the rollout of the Affordable Care Act (ACA), including the botched launch of HealthCare.gov and the concurrent wave of plan cancellations, the administration remains optimistic about the ACA’s fate.

However, critics of the ACA have seized upon these recent mishaps, particularly President Obama’s pledge that “if you like your health plan, you can keep your health plan,” as evidence of the inevitable demise of the ACA.

In response to this political firestorm, the Obama administration decided to allow insurers to renew plans not complying with ACA regulations, subject to the approval of state health insurance commissioners.

Under the policy announced last November, plans failing to meet ACA standards could be renewed for one year starting as late as Oct. 1, 2014 (and hence could be continued until Oct. 1, 2015).

The extension announced last week allows individuals to keep such plans until Oct. 1, 2017.

Allowing people to keep plans out of compliance with the ACA could deprive the newly-created marketplaces, where lower- to middle-class families can receive subsidies from the government to purchase private individual coverage, of enrollees, particularly the young and healthy enrollees they need to make premiums affordable.

According to ACA critics, meager enrollment of the young and healthy in the marketplaces would lead to a death spiral, a self-reinforcing cycle of premium increases and enrollment declines that could spell doom for the system. Recent data released by the Department of Health and Human Services suggests that enrollment, particularly among young adults, has been lackluster, falling short of Obama administration targets.

Is a death spiral looming?  Our analysis suggests not.

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