Singapore, which we wrote about in October, tinkers with its health care system all the time. Taiwan, in contrast, revamped its top to bottom.
Less than 25 years ago, Taiwan had a patchwork system that included insurance provided for those who worked privately or for the government, or for trade associations involving farmers or fishermen. Out-of-pocket payments were high, and physicians practiced independently. In March 1995, all that changed.
After talking to experts from all over the world, Taiwan chose William Hsiao, a professor of economics at the Harvard T.H. Chan School of Public Health, to lead a task force to design a new system. Uwe Reinhardt, a longtime Princeton professor, also contributed significantly to the effort. (Mr. Reinhardt, who died last month, was a panelist on an Upshot article comparing international health systems in a tournament format.) The task force studied countries like the United States, Britain, France, Canada, Germany and Japan.
In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s. At first, things did not go as well as hoped. Although the country had been planning the change for years, it occurred quite quickly after democracy was established in the early 1990s. The system, including providers and hospitals, was caught somewhat off guard, and many felt that they had not been adequately prepared. The public, however, was much happier about the change.
Today, most hospitals in Taiwan remain privately owned, mostly nonprofit. Most physicians are still either salaried or self-employed in practices.
The health insurance Taiwan provides is comprehensive. Both inpatient and outpatient care are covered, as well as dental care, over-the-counter drugs and traditional Chinese medicine. It’s much more thorough than Medicare is in the United States.
Access is also quite impressive. Patients can choose from pretty much any provider or therapy. Wait times are short, and patients can go straight to specialty care without a referral.
Premiums are paid for by the government, employers and employees. The share paid by each depends on income, with the poor paying a much smaller percentage than the wealthy.
Taiwan’s cost of health care rose faster than inflation, as it has in other countries. In 2001, co-payments for care were increased, and in 2002, they went up again, along with premiums. In those years, the government also began to reduce reimbursement to providers after a “reasonable” number of patients was seen. It also began to pay less for drugs. Finally, it began to institute global budgets — caps on the total amount paid for all care — in the hope of squeezing providers into becoming more efficient.
Relative to the United States and some other countries, Taiwan devotes less of its economy to health care. In the early 2000s, it was spending 5.4 percent of G.D.P., and by 2014 that number had risen to 6.2 percent. By comparison, countries in the Organization for Economic Cooperation and Development spend on average more than 9 percent of G.D.P. on health care, and the United States spends about twice that.
After the most recent premium increase in 2010 (only the second in Taiwan’s history), the system began to run surpluses.
This is not to say the system is perfect. Taiwan has a growing physician shortage, and physicians complain about being paid too little to work too hard (although doctors in nearly every system complain about that). Taiwan has an aging population and a low birthrate, which will push the total costs of care upward with a smaller base from which to collect tax revenue.
Taiwan has done a great job at treating many communicable diseases, but more chronic conditions are on the rise. These include cancer and cardiovascular and cerebrovascular disease, all of which are expensive to treat.
The health system’s quality could also be better. Although O.E.C.D. data aren’t available for the usual comparisons, Taiwan’s internal data show that it has a lot of room for improvement, especially relating to cancer and many aspects of primary care. Taiwan could, perhaps, fix some of this by spending more.
As we showed in our battle of the health care systems, though, complaints can be made about every system, and the one in the United States is certainly no exception. For a country that spends relatively little on health care, Taiwan is accomplishing quite a lot.
Comparing Taiwan and the United States may appear to be like comparing apples and aardvarks. One is geographically small, with only 23 million citizens, while the other is vast and home to well above 300 million. But Taiwan is larger than most states, and a number of states — including Vermont, Colorado and California — have made pushes for single-payer systems in the last few years. These have not succeeded, however, perhaps because there is less tolerance for disruption in the United States than the Taiwanese were willing to accept.
Regardless of which health system you might prefer, Taiwan’s ambition showed what’s possible. It took five years of planning and two years of legislative efforts to accomplish its transformation. That’s less time than the United States has spent fighting over the Affordable Care Act, with much less to show for it.
Nursing is America's most trusted profession yet again, Gallup finds
'Trust plays an important role in the relationship between nurses and the patients we serve'
Advisory.com - December 26, 2017
For the 15th year in a row, respondents to a Gallup poll ranked nursing as the most trusted profession in the United States.
For the survey, released last month, 1,028 respondents 18 years or older were asked to rate 22 professions, including health care and non-health care professions, based on perceived honesty and ethical standards.
Findings
Eighty-four percent of respondents rated nurses' honesty and ethical standards as high or very high, the poll showed. Pharmacists ranked second at 67 percent.
In addition, 65 percent of respondents rated doctors' honesty and ethical standards as high or very high, and 59 percent rated dentists' honesty and ethical standards as high or very high.
"Healthy majorities of the American public continue to show a willingness to trust the honesty and ethical standards of health care providers,” Jim Norman writes for Gallup.
However, not all health care professionals scored higher than 50 percent by the poll's metric. According to the poll, honesty and ethical standards were considered high or very high among:
Chiropractors, by 38 percent of respondents; and
Psychiatrists, by 38 percent of respondents.
Other professionals in the health care industry saw lower scores, with:
12 percent of respondents rating HMO managers' honesty and ethical standards as high or very high; and
11 percent rating insurance salespersons' honesty and ethical standards as high or very high.
Overall, the poll found only six of the 22 professions evaluated scored higher than 50 percent by the survey's metric, revealing that "Americans do not, by and large, rate the honesty and ethical standards of American professions highly,” Norman writes.
Pamela Cipriano, president of the American Nurses Association, said, "Whether nurses are by the bedside or in the board room, we continue to be a trusted resource and a vital part of our nation's health care system. This poll reflects the trust the public has in us, and we'll continue to work hard to keep that trust." She added, "Trust plays an important role in the relationship between nurses and the patients we serve" (Mongan, McKnight's, 12/20/16; Lightman, McClatchy DC, 12/19/16; American Nurses Association release, 12/19/16).
Years of Attack Leave Obamacare a More Government-Focused Health Law
by Robert Pear - December 26, 2017
WASHINGTON — The Affordable Care Act was conceived as a mix of publicly funded health care and privately purchased insurance, but Republican attacks, culminating this month in the death of a mandate that most Americans have insurance, are shifting the balance, giving the government a larger role than Democrats ever anticipated.
And while President Trump insisted again on Tuesday that the health law was “essentially” being repealed, what remains of it appears relatively stable and increasingly government-funded.
In short, President Barack Obama’s signature domestic achievement is becoming more like what conservatives despise — government-run health care — thanks in part to Republican efforts that are raising premiums for people without government assistance and allowing them to skirt coverage.
By ending the tax penalty for people who do not have coverage, beginning in 2019, Republicans may hasten the flight of customers who now pay the full cost of their insurance. Among those left behind under the umbrella of the Affordable Care Act would be people of modest means who qualify for Medicaid or receive sizable subsidies for private insurance.
“Republicans have inadvertently strengthened the hand of Democrats like me who prefer richer subsidies to a mandate and welcome the expanded federal role that will come with those subsidies,” said Joel S. Ario, a former insurance commissioner from Pennsylvania who worked in the Obama administration.
In days, the Trump administration is expected to carry out an executive order with proposed rules that would allow people to buy less expensive — and less comprehensive — coverage, through either business and professional associations or short-term private policies.
The Affordable Care Act’s success in reducing the number of uninsured owes more to Medicaid than to private health insurance. About 75 million people are now enrolled in Medicaid, a number that has increased by about one-third since the adoption of the Affordable Care Act. A smaller number, about 10 million, buy coverage from private insurers through the health law’s marketplace.
Among people ages 18 to 64, the proportion with private health insurance coverage is about the same today as in 2005, according to the National Center for Health Statistics. But the proportion with public insurance coverage has increased to more than 19 percent, from 11.5 percent in 2005, and the share of people in that age range who are uninsured has fallen to 12.5 percent, from about 19 percent.
In total, more than one-third of the population is covered with federal assistance, through Medicare, Medicaid, the Department of Veterans Affairs, the military and Affordable Care Act subsidies. (And that does not include the larger group of people who benefit from tax subsidies for health insurance provided by employers.)
Mr. Trump and Republicans in Congress failed this year in their efforts to cut Medicaid and could try again in 2018. Speaker Paul D. Ryan said this month that Republicans would try next year to slow the growth of federal health spending because “it’s the health care entitlements that are the big drivers of our debt.”
But Senator Mitch McConnell, the majority leader, has been leery of another run at health care in an election year, and it is possible that Medicaid could, in the near future, actually grow further under the Affordable Care Act. Maine voters approved a referendum last month to expand Medicaid in that state, though Maine’s Republican governor, Paul R. LePage, is dragging his feet. Mr. LePage will not be on the ballot in November, when the state could elect a governor more willing to accept the referendum’s results.
A Democratic wave election in November could also shift the balance of power in a few other state capitals.
While the marketplaces, or exchanges, have struggled with a series of problems since they opened in 2014, Medicaid, administered by an experienced corps of state officials, has gone from strength to strength. Public appreciation for the program has steadily increased as people come to understand its importance in the health care system, including its central role in combating the opioid epidemic.
And though Congress has effectively repealed the requirement for people to have health insurance, federal subsidies are still available to low- and moderate-income people who want insurance. The federal government pays, on average, about three-fourths of the premium for more than three-fourths of the people who buy insurance through the Affordable Care Act marketplace.
Insurers are still required to provide coverage to anyone who applies. They cannot deny coverage or charge higher premiums because of a person’s pre-existing conditions. And people receiving premium subsidies are generally insulated against insurance price increases.
By contrast, the sharp increases in premiums in many markets this year have made insurance less attractive and less affordable for middle-income people who do not receive subsidies. The brunt of premium increases falls on people who must pay the entire cost themselves — an individual with annual income over $48,240 or a family of four with income over $98,400.
Mr. McConnell says he remains committed to bringing to a vote early next year two bills to stabilize insurance markets. One would restore government subsidies to insurance companies to help cover out-of-pocket expenses for low-income customers. Another would offer money to states to lower premiums, perhaps by setting up “reinsurance” programs to cover the highest-cost customers with serious illnesses.
Mr. Trump appeared to embrace some kind of bipartisan health care legislation on Tuesday with a Twitter post from his resort in Palm Beach, Fla.: “Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!’’
But even with those measures, health policy experts say they expect the Affordable Care Act’s marketplaces to be populated increasingly by consumers who qualify for financial assistance or have clear medical needs.
“It seems to me that the exchanges will evolve into an extended form of government coverage very much akin to Medicaid,” said J. B. Silvers, a professor of health care finance at Case Western Reserve University, in Cleveland. Increasingly, he said, “those who are not subsidized will drop out because of the high prices, and those getting the subsidy will still see great bargains,” after taking account of the subsidies.
When the Affordable Care Act was passed in 2010, the Congressional Budget Office expected that the insurance exchanges would be more important than Medicaid in expanding coverage. The reverse has been true.
“Enrollment in the exchanges is nothing like what anyone expected,” said Daniel N. Mendelson, the president of Avalere Health, a research and consulting company. “Repeal of the mandate will probably serve to take out some relatively healthy people who think they can coast by without insurance. What we will have left is a heavily subsidized high-risk pool for low-income people who are not eligible for Medicaid.”
Medicaid covers substantially more people than Medicare, the insurance program for older Americans. Even though only 31 states have expanded Medicaid, total enrollment is about the same as what the Congressional Budget Office was predicting in 2010, when it assumed that all states would expand eligibility under the Affordable Care Act. The Supreme Court ruled in 2012 that the expansion of Medicaid was an option for states, not a requirement.
Congress’s decision to eliminate the individual mandate means that healthier people with less need for insurance are less likely to buy it. The remaining pool of insurance buyers will have higher costs, on average, so insurers will increase premiums even more. And when premiums rise, consumers are entitled to larger subsidies from the federal government to help defray the higher costs.
In some ways, Medicaid is more generous than commercial insurers. The benefits are more comprehensive, and coverage is nearly free, with beneficiaries required to pay only nominal amounts. While Medicaid is a government program, most states contract with private insurers to deliver and manage care.
Among the few companies that have been successful on the Affordable Care Act exchanges are insurers like Centene that have experience in Medicaid.
“The reason so many people are on Medicaid,” said Sara Rosenbaum, a professor of health law and policy at George Washington University, “is that so many people have low incomes.”
Poll says US citizens worry most about health care
by Emily Swanson and Ricardo Alsonso Zaldivar - Christian Science Monitor - December 21. 2017
Washington—As President Trump completes his first year in office, Americans are increasingly concerned about health care, and their faith that government can fix it has fallen.
A new poll by The Associated Press-NORC Center for Public Affairs Research finds that 48 percent named health care as a top problem for the government to focus on in the next year, up 17 points in the past two years.
The poll allows Americans to name up to five priorities and found a wide range of top concerns, including taxes, immigration, and the environment. But aside from health care, no single issue was named by more than 31 percent.
And 7 in 10 of those who named health care as a top problem said they had little to no confidence that government can improve matters. The public was less pessimistic in last year's edition of the poll, when just over half said they lacked confidence in the problem-solving ability of lawmakers and government institutions.
"We are way up there on the cost, and as far as giving good health care, we are way down," said Rebekah Bustamante of San Antonio, a retired medical imaging technician. "Now in health care, you're a number."
Ms. Bustamante said she voted for Mr. Trump, but "he's learning on the job, and he's got a long way to go."
Trump initially promised his own plan that would deliver "insurance for everybody" and "great" health care, "much less expensive and much better." But the White House never released a health care proposal from the president.
GOP legislation to repeal and replace former President Barack Obama's health care law failed in Congress, although the tax bill scraps the Obama requirement that most people get health insurance. Bloodied on both sides, Republicans and Democrats seem to have battled to an uneasy draw on health care.
Meanwhile, conflicting policy signals from Washington, including an abrupt White House decision to cancel insurer subsidies, roiled insurance markets. Premiums on health plans purchased by individuals jumped by double digits. Progress reducing the number of uninsured stalled, and one major survey found an uptick this year.
"There is zero bipartisanship, and it's frustrating," said Eric Staab, a high school teacher from Topeka, Kan. "It seems like we have thrown everything at this dartboard, and nothing is improving the coverage."
Rumblings of discontent have political repercussions for next year's midterm elections and the presidential contest in 2020, said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health, who follows opinion trends on health care.
"It's the issue that won't go away," said Professor Blendon. "Given the news cycle, taxes should be first, the economy should be second, and this health care thing should be buried."
Three in 10 Americans listed taxes among their top priorities, about double the percentage who said that last year. About a quarter mentioned immigration, and just under 2 in 10 mentioned environmental issues and education. Meanwhile, concerns about unemployment plunged to 14 percent, about half the mentions as last year.
Health care was by far the top issue mentioned by Democrats and independents. Republicans were about equally likely to mention immigration, health care, and taxes.
Democrats were more likely than Republicans to say they have little to no confidence that the government will make progress on health care, 84 percent to 57 percent.
The reason health care doesn't fade away is that costs aren't getting any more manageable, said some people who took part in the AP-NORC survey.
Bustamante said she is planning a trip to Mexico for some dental work, because she can obtain quality service for much less there. "Thank God I live in Texas, where getting to Mexico isn't that far away," she said. "But everybody doesn't have that option."
ShyJuan Clemons of Merrillville, Ind., said he's currently uninsured because his previous health plan was costing too much money for the benefit he got from it. He faced his insurance plan's annual deductible when he went to the doctor, so he'd wind up paying out-of-pocket for visits, on top of premiums.
"You are not constantly worried about taxes, but you are constantly worried about health care – be it major or minor," said Mr. Clemons, a personal care attendant who works with disabled people. "You catch a cold, and you just think about it in passing – 'I hope it doesn't develop into a problem.'"
Clemons, a Democrat, said he's disappointed that Trump and Republicans in Congress seem to be trying to tear down "Obamacare" instead of building on it. "I would like to see them make the thing run smoothly so we can do better, instead of just trying to cripple it," he said.
The lack of confidence in the ability of government to find pragmatic solutions extended to other problems in the AP-NORC poll, including climate change, immigration, and terrorism.
Just 23 percent said that Trump has kept the promises he made while running for president, while 30 percent said he's tried and failed, and 45 percent said he has not kept his promises at all.
Nearly 2 in 3 said they were pessimistic about the state of politics in the US About half were downbeat about the nation's system of government, and 55 percent said America's best days are behind.
The AP-NORC poll surveyed 1,444 adults from Nov. 11-Dec. 4 using a sample drawn from NORC's probability-based AmeriSpeak panel, which is designed to be representative of the US population. The margin of sampling error for all respondents is plus or minus 3.7 percentage points.
Freed From the iPhone, the Apple Watch Finds a Medical Purpose
By DISUSE WAKABAYASHI - NYT - December 26, 2017
SAN FRANCISCO — In the last months of Steve Jobs’s life, the Apple co-founder fought cancer while managing diabetes.
Because he hated pricking his finger to draw blood, Mr. Jobs authorized an Apple research team to develop a noninvasive glucose reader with technology that could potentially be incorporated into a wristwatch, according to people familiar with the events, who asked not to be identified because they were not authorized to speak on behalf of the company.
It was one of many medical applications that Apple considered for the Apple Watch, which debuted in 2015. Yet because many of the health features proved unreliable or required too many compromises in the watch’s size or battery life, Apple ended up positioning the device for activity tracking and notifications instead.
Now, the Apple Watch is finding a medical purpose after all.
In September, Apple announced that the Apple Watch would no longer need to be tethered to a smartphone and would become more of a stand-alone device. Since then, a wave of device manufacturers have tapped into the watch’s new features like cellular connectivity to develop medical accessories — such as an electrocardiogram for monitoring heart activity — so people can manage chronic conditions straight from their wrist.
What’s happening with the Apple Watch is one of the first signs of a leap forward in the utility of wearable devices. Many people had wondered why they would need a smart watch at all when most already carried more powerful smartphones with them. But as the Apple Watch becomes capable of handling more medical tasks on its own, they may now have an answer.
“This is an important step in the evolution of wearables,” said Tim Bajarin, president of Creative Strategies, an advisory and research firm. “The Apple Watch can now be on you all the time doing this type of medical monitoring.”
The Apple Watch has dominated competitors in the nascent smart watch market, but it has not taken a place alongside the iPod, iPhone and iPad as the next breakthrough Apple product. Apple does not disclose specific sales numbers for the watch, but the company has said its sales have risen 50 percent compared with a year earlier for three straight quarters. An Apple spokeswoman declined to comment further.
A digital health revolution has been predicted for years, of course, and so far has been more hype than progress. But the hope is that artificial intelligence systems will sift through the vast amounts of data that medical accessories will collect from the Apple Watch and find patterns that can lead to changes in treatment and detection, enabling people to take more control of how they manage their conditions instead of relying solely on doctors.
Vic Gundotra, chief executive of AliveCor, a start-up that makes portable electrocardiograms, said this would put patients on a more equal footing with doctors because they would have more information on their own conditions.
“It’s changing the nature of the relationship between patient and doctor,” he said, adding that doctors will no longer be “high priests.”
Last month, AliveCor introduced a band for the Apple Watch with a built-in electrocardiogram, or EKG, to detect irregular heart activity such as atrial fibrillation, a form of arrhythmia and a potential cause of a stroke. AliveCor uses the watch’s heart rate monitor to alert patients to take an EKG when their pulse quickens or slows unexpectedly.
The band, known as the KardiaBand, was the first Apple Watch accessory approved by the Food and Drug Administration. When a thumb is placed on the band’s sensor, EKG readings are taken in 30 seconds and sent wirelessly to the patient’s cardiologist. That helps resolve one of the biggest headaches in detecting atrial fibrillation — catching it during an episode so a cardiologist can properly assess it.
Elena Remus, 36, a digital marketing consultant from Alameda, Calif., has experienced what the KardiaBand can do. She had suffered heart palpitations on and off for the last five years, but there was little her doctors could do because they were never able to catch the incidents in real time.
Shortly after buying a KardiaBand for her Apple Watch a few weeks ago, Ms. Remus felt the onset of palpitations as she was making morning coffee. She looked down at her watch and saw that her normal heart rate of around 75 beats a minute had surged to 205 beats a minute. She started taking an EKG reading on her wrist and was finally able to record the activity, allowing her doctor to diagnose her condition as atrioventricular nodal re-entrant tachycardia — or in nonmedical speak, an abnormally fast heart rhythm — and plan a course of treatment.
“Now, I don’t feel like I’m going to pass out at home alone,” Ms. Remus said.
Apple is also looking for its own medical breakthroughs. Last month, the company announced a joint research study with the Stanford University School of Medicine to see whether the Apple Watch’s heart rate sensors could detect irregular heart activity without an electrocardiogram to notify people who might be experiencing atrial fibrillation.
Apple is also looking at potentially building an electrocardiogram into future models of the Apple Watch, according to a person familiar with the project, who spoke on the condition of anonymity because the details were confidential. It is unclear whether the EKG development, earlier reported by Bloomberg, would be introduced; such a product would most likely require F.D.A. clearance.
Separately, Apple is continuing research on a noninvasive continuous glucose reader, according to two people with knowledge of the project. The technology is still considered to be years away, industry experts said.
The current solution used by many diabetics is also coming to the Apple Watch. Dexcom, a maker of devices measuring blood sugar levels for diabetics, said it was awaiting F.D.A. approval for a continuous glucose monitor to work directly with the Apple Watch. Continuous glucose monitors use small sensors to pierce the skin to track blood sugar levels and relay those readings through a wireless transmitter.
Kevin Sayer, Dexcom’s chief executive, said that patients could opt for a monitor to communicate directly with the watch for convenience, but that the big payoff could come with combining sleep or activity data from the watch with glucose readings from its device to find correlations.
“We’re just beginning to unlock the potential of that data,” Mr. Sayer said.
Health care professionals said there was a risk of too much information. Dr. Khaldoun Tarakji, a cardiac electrophysiologist at Cleveland Clinic, said doctors needed to guide patients about who would benefit from more information and how much data was the right amount.
“We need to think about when too much information becomes just noise,” said Dr. Tarakji, who has worked with AliveCor to test KardiaMobile, a portable electrocardiogram that works with iPhones.
A flood of information, albeit potentially useful, may overwhelm doctors instead of assisting them. Initially, KardiaMobile patients sent their doctors an email each time they took an EKG reading. The flood of emails became confusing and raised questions about where the doctor should store that information. In response, AliveCor introduced a software platform for doctors that could populate the readings from patients and help detect early signs of atrial fibrillation.
“A wearable device does not equal a wearable physician,” Dr. Tarakji said. “As a medical community, we have to be intelligent about how to use these new technologies.”
How Big Tech Is Going After Your Health Care
by Natasha Singer - NYT - December 26, 2017
heart study prominently featured.
People often learn about new research studies through in-person conversations with their doctors. But not only did this study, run by Stanford University, use a smartphone to recruit consumers, it was financed by Apple. And it involved using an app on the Apple Watch to try to identify irregular heart rhythms.
Intrigued, Mr. Poston, who already owned an Apple Watch, registered for the heart study right away. Then he took to Twitter to encourage others to do likewise — suggesting that it was part of a breakthrough in health care.
“It’s not inconceivable, by the time I graduate from medical school,” Mr. Poston said, “that the entire practice of medicine can be revolutionized by technology.”
Apple, Google, Microsoft and other tech giants have transformed the way billions of us communicate, shop, socialize and work. Now, as consumers, medical centers and insurers increasingly embrace health-tracking apps, tech companies want a bigger share of the more than $3 trillion spent annually on health care in the United States, too. The Apple Heart Study reflects that intensified effort.
The companies are accelerating their efforts to remake health care by developing or collaborating on new tools for consumers, patients, doctors, insurers and medical researchers. And they are increasingly investing in health start-ups.
In the first 11 months of this year, 10 of the largest tech companies in the United States were involved in health care equity deals worth $2.7 billion, up from just $277 million for all of 2012, according to data from CB Insights, a research firm that tracks venture capital and start-ups.
Each tech company is taking its own approach, betting that its core business strengths could ultimately improve people’s health — or at least make health care more efficient. Apple, for example, has focused on its consumer products, Microsoft on online storage and analytics services, and Alphabet, Google’s parent company, on data.
“The big-picture reason that a lot of these tech companies are getting into health care now is because the market is too big, too important and much too personal to their users for them to ignore,” said John Prendergass, associate director of health care investment at Ben Franklin Technology Partners, a nonprofit organization in Philadelphia.
Physicians and researchers caution that it is too soon to tell whether novel continuous-monitoring tools, like apps for watches and smartphones, will help reduce disease and prolong lives — or just send more people to doctors for unnecessary tests.
“There’s no shortage of hype,” said Dr. Eric Topol, a digital medicine expert who directs the Scripps Translational Science Institute in San Diego. “We’re in the early stages of learning these tools: Who do they help? Who do they not help? Who do they provide just angst, anxiety, false positives?”
The tech industry is certainly no stranger to health. IBM, Intel and Microsoft have long provided enterprise services to the health care industry.
But now they, and other companies, are more visibly focused on creating, or investing in, new kinds of technologies for doctors, patients and consumers.
This year, Amazon was one of the investors in a financing round for Grail, a cancer-detection start-up, which raised more than $900 million. Apple acquired Beddit, a maker of sleep-tracking technology, for an undisclosed amount.
And Alphabet, perhaps the most active American consumer tech giant in health and biotech, acquired Senosis Health, a developer of apps that use smartphone sensors to monitor certain health signals, also for an undisclosed amount.
Alphabet also has a research unit, Verily Life Sciences, dedicated to developing new tools to collect and analyze health data.
This year, Verily introduced a health research device, the Verily Study Watch, with sensors that can collect data on heart rate, gait and skin temperature. Now, the watch is to be used in a research study, called Project Baseline and financed by Verily, to follow about 10,000 volunteers.
Participants in the Project Baseline study will also be asked to use sleep sensors in their beds, and to have blood, genetic and mental health tests. Using data analytics and machine learning, researchers hope to get a more detailed picture of the progression of diseases like cancer.
“We are creating devices that collect information, new molecular assays — and all of that is just to try to understand health at a deeper level,” said Dr. Jessica L. Mega, Verily’s chief medical officer.
Apple is taking a different approach — using its popular iPhone and Apple Watch to help consumers better track and manage their health.
“Apple is trying to drag medicine from where it currently takes place — in hospitals and clinics — and move it to the consumer side, to your phone,” said Malay Gandhi, an executive in residence at Greylock Partners, a venture capital firm.
In 2015, Apple introduced new software, called Apple ResearchKit, for health researchers. Stanford used it to develop an app to enroll volunteers in a heart study and track their physical activities, sleeping hours and fitness.
Dr. Lloyd B. Minor, dean of the Stanford University School of Medicine, said the app enabled researchers to smoothly enroll more than 54,000 patients — a large number for a study conducted by one medical center — and collect much more data than they could have otherwise.
“For us, it was an eye-opener,” he said.
Stanford is also conducting the Apple Heart Study. It is intended to determine whether an app for the Apple Watch can accurately detect irregular heart rhythms — particularly those associated with atrial fibrillation, a condition that can lead to blood clots and strokes.
If the app detects irregular heart rhythms, it will send participants a notification and offer them a free video consultation with a doctor. The study is not designed to assess whether people who used the watch app had a reduced incidence of stroke and cardiac death compared with people who did not use the app.
Microsoft, already a major supplier of software and cloud services to medical centers, is also ramping up its health business.
This year, the company announced an initiative, Healthcare NeXT, to create products for medical providers and patients using artificial intelligence and cloud services like speech recognition.
As part of the effort, Microsoft worked with the University of Pittsburgh Medical Center to develop digital services intended to reduce drudgery for physicians and improve patients’ experiences. One project involves a virtual assistant that would take notes on conversations between a doctor and a patient, analyze the conversation and then send a summary to the patient’s electronic medical record. The medical center is also pilot-testing an app that notifies doctors when one of their patients has filled a prescription at a U.P.M.C. pharmacy.
Microsoft developed a platform to enable medical centers to create virtual assistants for patients. Aurora Health Care, a nonprofit based in Milwaukee, used it to create a health bot that helps patients decide which medical specialists to see and to make appointments.
“We’re really focusing on what people in the health care world are doing today and how we can make it better,” said Peter Lee, Microsoft’s corporate vice president for artificial intelligence and research.
Facebook, too, has been expanding its business and research efforts in the health sector.
Last year, Facebook made it more appealing for pharmaceutical companies to advertise their medicines on the platform by introducing a rolling scroll feature where drug makers can list their drug’s side effects in an ad. Such risk disclosures are required by federal drug marketing rules.
And this year, Oculus, the virtual reality gear maker owned by Facebook, teamed up with Children’s Hospital Los Angeles to develop V.R. simulations for doctors and medical students to practice handling high-risk pediatric medical emergencies.
Amazon has been less public about its plans in health. But industry analysts have speculated that Amazon could enter the pharmacy business.
Dr. Topol of Scripps said tech companies had an opportunity to remake longstanding, cumbersome systems — like hospital alarms at a patient’s bedside that go off dozens of times every day — and re-envision how health care is delivered.
“There’s not one tech company that isn’t involved one way or another,” Dr. Topol said. “Many of the companies see this as somewhere between rescue and a great business opportunity.”
Think You’re Seeing More Drug Ads on TV? You Are, and Here’s Why
by Joanne Kaufman - NYT - December 24, 2017
Swelling of legs, hands and feet; capillary leak syndrome; fever; muscle pain; unusual bruising; dizziness, blurry vision; rash; hives; blisters; nervous system and blood disorders; lymphoma; swollen tongue; dry mouth; weight gain; inability to fight infections; nausea, diarrhea; constipation; depression; dehydration; suicidal thoughts.
Oh, and death.
These are just some of the side effects mentioned in television advertisements for prescription drugs.
And while these kinds of ads have been running for 20 years, ever since the Food and Drug Administration approved them, it is not your imagination if you think you are seeing more of them these days. Lots more.
According to Kantar Media, a firm that tracks multimedia advertising, 771,368 such ads were shown in 2016, the last full year for which data is available, an increase of almost 65 percent over 2012.
“TV ad spending by pharmaceutical companies has more than doubled in the past four years, making it the second-fastest-growing category on television during that time,” Jon Swallen, Kantar’s chief research officer, said.
And where are viewers most likely to encounter ads for Lyrica (a pill for diabetic nerve pain, among other ailments), Humira (a drug for rheumatoid arthritis), Eliquis (an anticoagulant that is meant to treat blood clots and to lower the risk of strokes) and other prescription medications? Dramas and news shows, according to data from Nielsen.
The ads, which once focused on treatments for chronic but generally nonfatal conditions, have turned to more serious ailments in the last few years, said Thomas Lom, a consultant and former senior executive at several health care ad agencies.
“In the old days, it was allergies and acid reflux and whatnot,” he said. “Now, it’s cardiology issues. It’s cancer.”
That, of course, reflects the medical issues facing audiences that skew older.
“The drug companies aren’t generally marketing to people in their 30s; they’re marketing to the 65-plus, and that’s the population that tends to still be watching television,” said Allen Adamson, a brand strategy consultant.
And when the ads come on, that audience is also listening intently to all that can befall them if they take a certain drug. An unexpected side effect of ad agency compliance with the drug administration’s regulation, it turns out, is enhanced credibility.
“It’s counterintuitive, but everything in our research suggests that hearing about the risks increases consumers’ belief in the advertising,” said Jeff Rothstein, the chief executive officer of Cult Health, an ad agency that specializes in health care.
As Howard Courtemanche, president of the health and wellness practice at Young & Rubicam, put it, “What is seemingly a negative to people who don’t have a condition or disease is a positive to people who suffer from it because they’re thinking, ‘Well, of course it has side effects. It’s fighting a really serious illness.’ They’ll say, ‘I’m in a life-or-death situation and I want a drug that’s really strong. I expect there to be risk to get the rewards.’ ”
Still, that interest goes only so far.
“At some point, the side effects become white noise,” said Maryann Kuzel, who oversees analytics at Publicis Health, a unit of the communications company Publicis Groupe. “There’s a huge amount of information compressed into a 60-second commercial, more so than any other industry.”
“You have the benefits of the drug,” she said. “You have the specific patient population the drug is intended to treat. You have the dosing mechanism. Is it oral or is it an injection? Where is it administered? How frequently do you need to take it? And, of course, you have all the side effects. And we know that consumers are multitasking across multiple devices while they’re watching TV. So comprehending all that information is a tall order for consumers.”
Price of 40-year-old cancer drug hiked 1,400% by new owners
by Jonathan Berr - Moneywatch - December 26, 2017
Prices for a cancer drug called lomustine have skyrocketed nearly 1,400 percent since 2013, putting a potentially life-saving treatment out of reach for patients suffering from brain tumors and Hodgkin's lymphoma. Though the 40-year-old medication is no longer protected by patents, no generic version is available.
According to the Wall Street Journal, lomustine was sold by Bristol-Myers Squib for years under the brand name CeeNU at a price of about $50 a capsule for the highest dose. The drugmaker sold lomustine in 2013 to a little-known Miami startup called NextSource, which proceeded to hike lomustine's price nine times since. It now charges about $768 per pill for the medication.
According to an analysis done for the Journal by Truveen Health Analytics and Elsevier, NextSource this year raised prices for the drug, which it rebranded as Gleostine, by 12 percent in November following a 20 percent increase in August.
NextSource CEO Robert DiCrisci, told the Journal that the company sets its prices based on the costs it incurred in developing the medication and the benefits it provides patients. Like other drugmakers, the company provides discounts and financial assistance to those who can't afford its cost. A spokesperson for NextSource didn't respond to an email requesting comment for this story.
Henry S. Friedman, a professor of neurosurgery at Duke University School of Medicine, accused NextSource of "price-gouging" in an interview with the Journal, adding: "People are not going to be able to afford it, or they're going to pay a lot of money and have financial liability."
According to the Journal, the U.S. Food and Drug Adminstration is offering to expedite the regulatory review process for more than 300 drugs like lomustine that lack generic competitors although their patents have expired, part of the Trump administration's overall effort to lower pharmaceutical prices. Whether there is enough demand for a niche product like lomustine is hard to say, however.
Soaring prices for cancer drugs are a concern for both patients and doctors because financial pressures can lead to delays in seeking treatment that can easily surpass six figures per year. A study published earlier this year in the Journal of Clinical Oncology found prices for 24 patented injectible Medicare Part B drugs rose an average of 18 percent annually over the past eight years on an inflation-adjusted basis. Prices continued to rise even when generic versions of the drug became available.
Patients with cancer are among the most likely to feel the pain of recent drug price hikes. Novartis (NVS), the Swiss drugmaker, is charging $475,000 per patient for its Kymriah treatment for certain types of blood cancers. Another blood cancer medication developed by Gilead Sciences (GILD) called Yescarta costs $373,000. (According to Bloomberg News, patients have experienced delays in getting the breakthrough treatment because of payment delays by both private insurers and Medicare and Medicaid.) The brain tumor treatment called Alecensa is priced at nearly $160,000 a year.
In medicine, the term “evidence-based” causes more arguments than you might expect.
And that’s quite apart from the recent political controversy over why certain wordswere avoided in Centers for Disease Control and Prevention budget documents.
The arguments don’t divide along predictable partisan lines, either.
The mission of “evidence-based medicine” is surprisingly recent.Before its arrival, much of medicine was based on clinical experience. Doctors tried to figure out what worked by trial and error, and they passed their knowledge along to those who trained under them.
Many were first introduced to evidence-based medicine through David Sackett’s handbook, first published in 1997. The book taught me how to use test characteristics, like sensitivity and specificity, to interpret medical tests. It taught me how to understand absolute risk versus relative risk. It taught me the proper ways to use statistics in diagnosis and treatment, and in weighing benefits and harms.
It also firmly established in my mind the importance of randomized controlled trials, and thegreat potential for meta-analyses, which group individual trials for greater impact. This influence is apparent in what I write for The Upshot.
But evidence-based medicine is often described quite differently.
Many of its supporters say that using evidence-based medicine can address the problems of cost, quality and access that bedevil the health care system. If we all agree upon best practices — based on data and research — we can reduce unnecessary care, save money and push people into pathways to yield better results.
Critics of evidence-based medicine, many of them from within the practice of medicine, point to weak evidence behind many guidelines. Some believe that medicine is more of an “art” than a “science” and that limiting the practice to a cookbook approach removes focus from the individual patient.
Some of these critics (as well as many readers who comment on my articles) worry that guidelines line the pockets of pharmaceutical companies and radiologists by demanding more drugs and more scans. Others worry that evidence-based medicine makes it harder to get insurance companies to pay for needed care. Insurance companies worry that evidence-based recommendations put them on the hook for treatment with minimal proven value.
Everyone is a bit right here, and everyone is a bit wrong. This battle isn’t new; it has been going on for some time. It’s the old guard versus the new. It’s the patient versus the system. It’s freedom versus rationing. It’s even the individual physician versus the proclamations of a specialized elite.
Because of the tensions in that last conflict, this debate has become somewhat political.
The benefits of evidence-based medicine, when properly applied, are obvious. We can use test characteristics and results to make better diagnoses. We can use evidence from treatments to help people make better choices once diagnoses are made. We can devise research to give us the information we are lacking to improve lives. And, when we have enough studies available, we can look at them together to make widespread recommendations with more confidence than we’d otherwise be able.
When evidence-based medicine is not properly applied, though, it not only undermines its reasons for existence, but it also can lead to harm. Guidelines — and there are many — are often promoted as “evidence-based” even though they rely on “evidence” unsuited to its application. Sometimes, these guidelines are used by vested interests to advance an agenda or control providers.
Further, too often we treat all evidence as equivalent. I’ve lost track of the number of times I’ve been told that “research” proves I’m wrong. All research is not the same. A hierarchy of quality exists, and we have to be sure not to overreach.
There is a difference between statistical significance and clinical significance. Get a large enough cohort together, and you will achieve the former. That by itself does not ensure that the result achieves clinical significance and should alter clinical practice.
Finally, we have to recognize that even when good studies are done, with clinically significant results, we shouldn’t over-extrapolate the findings. Just because something worked in a particular population doesn’t mean we should do the same things to another group and say that we have evidence for it.
Years ago, Trisha Greenhalgh and colleagues wrote an article in the BMJ citing evidence-based medicine as “a movement in crisis.”It argued that we’ve moved too much from focusing on disease to risk. This point, more than any other, highlights the problem evidence-based medicine seems to have in the public sphere.
Too many articles, studies and announcements are quick to point out that something or other has been proved to be dangerous to our health, without a good explanation of the magnitude of that risk, or what we might reasonably do about it.
Big data, gene sequencing, artificial intelligence — all of thesemay provide us with lots of information on how we might be at risk for various diseases. What we lack is knowledge about what to do with what we might learn.
If evidenced-based medicine is to live up to its potential, it seems the focus should be on that side of the equation as well, instead of taking best guesses and calling them evidence-based. This, probably more than anything else, has made the term so widely mistrusted.
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