Friday, August 29, 2014

Get ready for the “Uberization” of Medicine

Even if you don’t live in a city yet that offers Uber’s rideshare app, you probably have heard about it, because the media has widely reported on job actions by taxi cab drivers—and the gridlocked traffic that resulted—that have taken place in Washington DC and in other major cities across the world including London, Berlin, Paris and Madrid. Uber is an “on demand” smart phone app that allows users to summon private drivers to pick them up from wherever they happen to be, usually within minutes; the independent drivers that contract with Uber own their own cars and pass background checks but do not have to meet the numerous regulations (and in some cities, medallion fees) applicable to licensed taxi drivers. By  generally offering more convenient, and sometimes lower cost access to rides than those available from licensed taxi drivers, Uber is displacing many established taxi drivers and companies—a classic case of a disruptive innovation, “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”

What does this have to do with medicine? Well, there are now a number of Uber-type apps that promise to do to medicine what Uber has done to taxis—bring consultations by physicians to patients via their smart phones, on demand, wherever and whenever they request them. You can see a sampling of the services and what they claim to offer here.

One big difference between these services and Uber’s ride sharing app is that they provide access to virtual consultations by fully licensed (and in many cases, the apps claim, board certified) physicians, so the competition is potentially between licensed physicians in traditional brick-and-mortar practices, and licensed physicians who contract with the app companies to provide consultations via smart phone. (They could also be physicians in traditional practices who contract to do smart phone consultations on the side). Yet I can see the potential for these services to be another disruptive innovation if a growing number of patients decide they would prefer to get an on-demand access to a physician, and get their symptoms “diagnosed” and their prescriptions filled immediately, via a few minutes on a smart phone, without having to wait for an appointment and then having to schlep to the doctor’s office. All for about $40 per smart phone consult.

One has to ask, though, what do these apps do to quality?  Continuity of care and the patient-physician relationship?  I perused one such company’s site, American Well, which promises that “Your conversation with your doctor will last about 10 minutes. That’s how long it takes to handle most problems, but of course you can add time if you need to. Doctors can review your history, answer questions, diagnose, treat and even prescribe medication. And your prescriptions will be sent straight to your pharmacy.” (By providing their link, I am by no means endorsing or reviewing their services, just offering the link so that you can also see what I found).

I put in my zip code, and found several board certified family physicians who said they were available for an immediate consultation—at 5:05 p.m. on a Thursday evening! I looked at the credentials of the listed physicians, and all were board certified. I didn't ask for a consultation, but it appears that I could have gotten one right away.

I then checked on the reviews in the App Store from people who claim to have actually used the app. There were 26 reviews, and the overall user rating was just a hair off of five stars, the highest. Yet some of the reviewers’ comments gave me pause:

“The only place where you can see an amazing, friendly helpful doctor in a matter of minutes-right from your phone! I used it for cold/respiratory symptoms and was able to see the doctor and get treatment recommendations in less than 2 minutes.”

“Near me, there are a few urgent care places...but I usually have to wait at least an hour.  This time, I used this app, talked to a doctor, and had a prescription sent to my pharmacy within like 20 minutes. Saved me a ton of time.”

“In less than a minute, I was talking to a live and knowledgeable doctor, in the comfort of my home. The doctor truly cared about my health and my prescriptions were sent to my regular pharmacy!”

“I had developed a cold and was placed on antibiotics. A few weeks later my cold returned with an unbearable sore throat, rash on my forehead, and yeast infection as a result of antibiotics I had been on. It was a Saturday night...I was able to use this app to have a video consult with a doctor at 11:30 p.m. The Dr. I spoke to wanted me to start something before I went to bed. She e-prescribed 4 RXs directly to my 24 hour pharmacy. I picked up everything that night and woke up feeling so much better."

Now, as readers of this blog know, I am not a clinician, and so cannot comment on the appropriateness of the care described in these reviews (and the reviews themselves may not be accurate). But I have to ask those of you who are clinicians whether you believe that it is truly possible to diagnose a patient’s condition, via a few minutes on a smart phone’s video screen, without a history and physical, and without knowing the patient, and prescribe the right medications if medications are even needed? Can these smart phone encounters replace the traditional patient-physician relationship and continuity of care? The hands-on physical exam? The tests and blood work often required before a diagnosis is given? Can they? Should they?

The experience with Uber shows that fighting technological innovation and competition from services like these in all probability won’t work. Just ask the cab drivers. If there are physicians willing to sign up for them, and patients willing to get their care from them, then these services will likely grow, and maybe begin to displace some traditional brick-and-mortar physician practices.

We live in an age when people want what they think they need now, without delay, whenever and wherever they want them. And such innovations could provide opportunities for physicians in more traditional practice arrangements to also get in the business of offering smart phone consultations with both new and established patients. Competition might also result in traditional practices offering more timely visits and after-hours access, in person or by emails and by phone—and they may have to, if they want to stay competitive.

We don’t know how the Uberization of Medicine will affect medical care, but you better get ready for it, because it is coming. And unlike Uber’s car sharing app, which is mainly available in large cities where there is huge demand for taxis, doctor consultations via a smart phone app could potentially be offered anywhere, to anyone, from the biggest cities to the most rural of areas—perhaps making it an even more disruptive innovation for medicine than Uber has been for taxis.

Today’s question: What is your reaction to the Uberization of Medicine?

Thursday, August 7, 2014

“Obamacare” is a lifeline, not a train wreck

For years, critics of Obamacare (Affordable Care Act), have predicted that it would turn out to be a “train wreck”—or something worse.  But now we know that by every objective measure, the ACA is working out pretty darn well.  Let’s run through the “train wreck” predictions, and what we now know to actually be the case:

Train wreck prediction #1:

“Obamacare will lead to skyrocketing health care cost increases and explode the deficit.”

Typical was the claim by Obamacare opponent Avik Roy that “healthcare spending will explode under Obamacare.”

But now we know that:

In 2012, total health care spending increased by 3.7%, the “lowest rate since 1960.” Most recently, the CBO substantially reduced its forecast of projected deficit spending, largely because of the slowdown in healthcare spending.  And the CBO’s director confirmed his agency’s long-standing view that the ACA will lower the deficit.

The ACA may not be totally responsible for the healthcare spending slow down—the same thing is happening in other wealthier countries reports the New York Times.

But the facts to date show that Obamacare surely has not caused health care cost increases to skyrocket, or the deficit to explode; rather, health care spending has slowed and deficits are going down.

Train wreck prediction #2:

“More people will lose coverage under Obamacare than gain it.”

Speaker of the House John Boehner was one of many ACA critics who made this claim.

But now we know that:

Far more people gained coverage than lost it.

The Washington Post’s independent fact-checker wrote in March that there’s “more than enough to demonstrate that no matter how you count it, there has been no net loss in insurance coverage.”

In fact, today we now know for sure that Obamacare has allowed far more previously uninsured people to gain health insurance coverage than lose it.  It’s not even close.  Kaiser Health News reports that three independent studies found that the ACA “reduced the number of uninsured adults by 8 to 11 million people”.  Politico, a highly respected, independent and non-partisan news source for DC policy wonks and politicians, concludes that “by now, the trend is unmistakable: Millions of people who didn’t have health insurance before the Affordable Care Act have gained it since last fall. The law is not just covering people who already had health coverage, but adding new people to the ranks of the insured — which was the point of the law all along.”

To recap, these are the plain and simple facts:

Opponents of Obamacare predicted that Obamacare would become a “train wreck” because health care spending would skyrocket and the deficit would explode as a result.  The fact is you’d have to go back over half a century to find a time when health care spending has  grown so slowly;  the CBO says that federal deficit spending is declining (largely due to the slowdown in healthcare spending), and that the ACA will continue to lower the deficit in the future.

Opponents of Obamacare predicted that it would become a “train wreck” because  millions more would lose coverage than gain it.  But the fact is that under Obamacare, the uninsured rate is the lowest it’s been since at least 2008, according to Gallup, with the rate dropping across nearly every subgroup—extending coverage to some 8 to 11 million previously uninsured adults.

For the millions who have gained coverage, Obamacare today is looking a lot more like a lifeline than a train wreck.

But it’s not only the uninsured who benefit.  Don’t we all share in the benefit of having  lower healthcare spending, lower deficits, and from seeing fewer of our neighbors delay getting needed health care because they couldn't afford health insurance?

Today’s questions:  Is Obamacare a train wreck or a lifeline?  And if you still think it is (or will become) a train wreck, what facts do you have to back that up?

Friday, August 1, 2014

Four Things You Need to Know about the IOM’s Call for GME Reform

On Tuesday, the Institute of Medicine issued a report that calls for major restructuring of Graduate Medical Education (GME) financing “to allow a transition to an accountable, performance-based system” to fund graduate medical education over the next ten years.  The report, coming from a prestigious and highly influential 21-person committee of experts, has created a firestorm of reaction—ranging from the American Association of Medical College’s dire warning that the IOM would “destabilize a system that has produced high-quality doctors and other health professionals for more than 50 years and is widely regarded as the best in the world” to the American Academy of Family Physicians (AAFP) applauding the IOM for its recommended overhaul even though  “AAFP has advocated for quicker change on a larger scale.”   ACP, in a statement issued today, found elements of the IOM report that it likes—and elements of concern.
This is what the fuss is all about:

1. The IOM would keep the aggregate amount of GME financing flat for a decade (with only adjustments for inflation).  Physician organizations (including ACP and AMA), the AAMC, and many outside experts believe that GME funding needs to be increased, across the board (AAMC and AMA) or selectively and strategically (ACP), to fund more residency positions in fields where there is a documented shortage, especially in primary care.

2. The IOM’s call for flat funding reflects its views that:

a. Current GME dollars are not being spent wisely or effectively: “Advocating for increased federal GME funding would be irresponsible without evidence that the public’s current level of investment is helping to produce the workforce needed in the 21st century. At the same time, Medicare GME funding should not be reduced from current levels if it can be leveraged for greater public benefit.”

b. There is “no credible data” that there will be a physician shortage, especially in primary care.  The IOM suggests that increased use of telemedicine, relying more on non-physicians including NPs and PAs, and changing primary care physicians’ roles “from being central to a more consultative role” could eliminate the shortage projected by other studies of anticipated supply and demand.

While ACP and many others in medicine would agree that current GME dollars could be spent more effectively and strategically, we strongly disagree with the IOM’s surprising conclusion that there is “no credible data” of a shortage of primary care physicians, or in other specialties.  From ACP’s statement on the IOM report:

“ACP is very concerned, however, that the IOM did not make recommendations that address the nation’s looming physician workforce crisis. We are particularly concerned that the IOM stated that it ‘did not find credible evidence’ to support claims that the nation is facing a looming physician shortage, particularly in primary care specialties. Paradoxically, the IOM also suggested that ‘GME funds might be used to finance new incentives for choosing a primary care career,’ even as it questioned whether a primary care shortage exists. Although we concur with the IOM that more research is needed to guide physician workforce policies and that incentives, including payment reform, are needed to encourage careers in primary care, we believe there is credible evidence of a real and growing shortage of primary care physicians for adults warranting immediate action. It is estimated by highly credible analyses that the nation will need 44,000 – 46,000 additional primary care physicians by 2025. This figure does not take into account the increasing demand for primary care services as an estimated 25 million uninsured Americans will obtain coverage through the reforms in the Affordable Care Act.”

3. The IOM would divide the flat aggregate dollar amount of GME funding into two pools, the Operational Fund, which would fund traditional GME programs, and a new Transformation Fund, which would “finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.”   Because overall GME funding would be budget neutral, money would be taken away from traditional GME programs funded by the Operational Fund to pay for the new Transformation Fund.

The result would be a redistribution from traditional teaching programs and affiliated hospitals, paid out of the Operational Fund, to grant-funded “innovative programs” paid out of the Transformation Fund.

(The Operational Fund allocations begin at 90 percent of the total Medicare GME fund, decrease to 70 percent over roughly 3 years and remain at that level for several years, and then return to 90 percent by the 10th year. The Transformation Fund would be allocated the balance of the funds - thus starting at 10 percent of the total, moving up to 30 percent as GME pilots and activities gear up and then returning to the 10 percent allocation as successful pilots and research establish the basis for broad application of GME improvement initiatives, including additional slots.)

It is this redistribution that has AAMC warning about  “destabilization” of a GME system that is “widely regarded as the best in the world.”  ACP, for its part, stated that it “joins with the IOM in its call for innovation and transformation in GME, including a greater emphasis on training in community-based settings, but we are very concerned that reducing GME payments to existing programs to fund innovation and transformation could do great harm to the educational mission of many teaching hospitals and the patients they serve.”

4. The IOM states that GME is a public good— it benefits all of society, not just those who directly purchase or receive it.  Yet the IOM rejected the idea of establishing an all-payer fund to finance GME,  arguing that Medicare funding provided more stability.  Advocates for all-payer funding, ACP included, argue that because GME is a public good, all payers should pay into it—and that spreading the pool of financing to include public and private payers would be less risky than relying mostly on Medicare.

Still, much of what the IOM recommends resonates with the ACP policy that “Payment of Medicare GME funds to hospitals and training programs should be tied to the nation’s health care workforce needs. Payments should be used to meet policy goals to ensure an adequate supply, specialty mix, and site of training.”  Going forward, ACP plans to analyze the IOM report further, “offering our suggestions in the spirit of building upon the many imaginative reforms recommended in the report. We will also continue to advocate for policies to ensure an adequate supply of physicians to meet the nation’s health care needs, including strategic increases in the number of Medicare-funded GME positions in primary care and other specialties facing shortages.”

Today’s question: What is your reaction to the IOM report?