HealthCommentary

Exploring Human Potential

ZIKA – What We Know and What We Don’t Know.

Posted on | February 5, 2016 | No Comments

Screen Shot 2016-02-05 at 11.46.27 AM

 

 

 

CDC source

Mike Magee

How much do we know about Zika?

Natural History:  Zika is a neurovirus transmitted across species by mosquitos. It was first described in the Zika Forest of Uganda, in 1947. Thus the name. Compared to two other viral infections endemic to the area – dengue and chikungunya – it was considered non-threatening to the population causing only minor symptoms in 20% of those infected. Within a short period of time, it spread to Asia, and then in 2007, jumped to the South Pacific islands, where an outbreak occurred in French Polynesia. In May, 2015, it first appeared in Brazil, a country of 200 million, where it spread rapidly.

How is Zika transmitted?

It’s transmitted primarily through a mosquito of the Aedes genus. These include the Aedes aegypti (yellow fever mosquito) and the Aedes albopictus (Asian tiger mosquito). The former is found in Florida and along the Gulf Coast, and the later can be found as far north as Chicago. They bred in any standing water.

It is now becoming clear that once a human has the virus it can be transmitted sexually to another human. Also a recent study found Zika may be present in mucous liquids raising additional questions regarding transmission.

Does Zika virus cause microcephaly in newborns and Guillain-Barre Syndrome (temporary paralysis in adults)?

Although there is no absolute proof that Zika caused outbreaks of these conditions, nor a strong theory on how the virus would accomplish this, the circumstantial evidence points to Zika as a causative agent in the recent outbreaks in both the French Polynesia and Brazil. In Brazil, where Zika is spreading rapidly, there have been 4000 cases in the past year of microcephaly in newborns coinciding with rapid spread of the virus. The normal number is 150 cases per year.

Where are there travel warnings for US citizens?

The travel warnings are being constantly updated at the CDC. Currently pregnant women are being discouraged from travel in South and Central America and in the Caribbean. Non-pregnant women who travel to these areas are being encouraged to take extra precautions to avoid becoming pregnant while traveling in these areas.

Are there tests for Zika?

Yes, Zika can be detected in blood and tissue samples. But it’s not easy, and requires a specialty lab and molecular identification. Development of simpler tests are underway. The current test does cross-react with dengue and yellow fever, so false positives have been a problem.

Why is there so much caution with pregnant women?

Obviously even the small possibility of a newborn developing microcephaly, which has no treatment and is usually accompanied by serious development problems, is frightening. Since 80% of those infected have absolutely no symptoms, it is difficult to be sure you have not been exposed. Also, it is not clear that the babies with microcephaly were delivered only by symptomatic mothers. At least some had no symptoms at all.

Does the virus hang around in the body, and potentially affect a baby conceived months after the original exposure?

The true answer is, we don’t know. But experts right now are saying the risk is “very, very low”.

Does the virus cross the placenta?

We don’t know, but if it causes microcephaly, it likely does in order to affect the developing brain in this way. Yellow fever and dengue viruses don’t cross the placenta, but rubella and cytomegalovirus can. The 1st trimester is when the fetus is most vulnerable.

Is there a treatment for Zika?

Since the symptoms are mild, anti-virals are not generally used. Work is underway on a vaccine.

Great resource article HERE.

Cross-Sector Partnerships and Public Health

Posted on | January 28, 2016 | No Comments

Screen Shot 2016-01-28 at 2.30.47 PMSource: NIH

Mike Magee

In an article this week in JAMA, titled “Aspirations and Strategies for Public Health”, the authors explore how best to position the role of Public Health in advancing population health.  Three points were especially noteworthy.

1. “Public health must engage the social, political, and economic foundations that determine population health.”

2. “The conditions that make people healthy often are outside what have historically been considered the remit of the health professions: health improvement now requires participation in politics and social structures.”

3.  “..public health advocates must work with actors across government, academia, industry, and not-for-profit sectors to achieve the goals of public health.”

These insights reinforce two important truisms:

1. Health is political.

2. Cross-sectors partnerships are essential.

Complex forces at work over the past two decades have created a myriad of social, economic and political challenges that demand cooperative and collaborative solutions.  Such cross-sector partnerships presume clear role delineation, well defined strategies and objectives and evolving relationships that challenge historic checks and balances.

The desire on the part of government, academics, non-governmental organizations and industry to forge new partnerships reflects the common belief that no one sector can address such complex challenges in isolation.  The rapid advance of technology has supercharged the environment accelerating globalization, regionalization and the rate of change in social institutions while virtually disintegrating geographic boundaries.  Success in forming stable and productive cross-sector relationships will largely determine the extent to which we are able to ensure societal justice and progress.

The rapid emergence of new technology has conspired to eliminate previously well-defined sector boundaries.  On a most fundamental level, these previously heavily segregated sectors now possess, in varying degrees, a common language and set of tools.  In addition, information and knowledge are no longer subject to reliable isolation whether by geography, class, gender, race or religion.  Finally, the acquisition and implementation of new information technologies have ignited a highly compressed, cross-sector and globally competitive exercise in process redesign that has fundamentally changed the way we communicate and do business with each other, and in the process ramped up expectations for progress absent a fundamental alteration in our human capacity to absorb change without destabilizing our societies.

Government, business, academics, and non-governmental organizations today confront a complex series of public challenges that no one sector can address in isolation. Each sector has well defined historic purposes, roles and strategies for success.  Appreciation of these unique traditional assets is a starting point in our common movement toward mutual appreciation and partnership.

Industry has focused on business performance, the creation of wealth, the discovery of new markets, the expansion of social engagement, the delivery of customer service, and expanding and aligning philanthropy with core mission.  Government has focused on purpose and governance, redefining basic roles and responsibilities, exploring centralized and decentralized approaches, tapping cross-sector expertise to expand efficiency, and developing skills as bridgers and collaborators in an effort to share responsibility for creation   and execution of sound policy.

Academics have traditionally focused on a mission of service, education and research. Today they confront diminishing resources and increasing demands for service and social action.  In response, they have emphasized reengineering of patient care processes to accomplish operational efficiencies, and constructive approaches to partnering emphasizing trust and transparency, with a constant eye on institutional integrity.

Non governmental organizations (NGO’s) have focused on shaping attitudes and behaviors of government, industry and academics.  This relatively new mission has been layered upon one of traditional service and activism directed at specific concrete objectives with a high degree of immediacy.  They have focused on virtual communications, organizational building, and campaign execution skillfully leveraging new low cost information technologies and high media credibility. 

Beyond a common understanding of the strengths and capabilities of each sector, and the desire for collaboration reflected in a willingness to mutually plan, to align goals and objectives and to share risk, there remains the issue of environmental readiness. What are the factors that must be in place to ensure success?

First, if it is true that all politics are local, so too are all successful cross-sector partnerships in so far as they acknowledge in their planning, design and management the realities of time, place, people and institutions in the target geography.

Second, in any cross-sector initiative in health, there should be some level of representation from each of the four sectors.  The partners must have a well-defined common need or public purpose that unites them.  What is that common passion?

Third, the proposed project or solution must be right sized to the problem or challenge at hand.  Too small and the effort will lack resources to ensure measurability and sustainability.  Too large and the effort will create structure without solution.

Fourth, human conditions must be right.  This includes identifiable optimistic leaders with the time and willingness to commit and a reservoir of good will among the players to support both innovation and implementation of the common vision, the structural integration, the joint governance and ongoing civic engagement.

Fifth, there needs to be accurate information and baseline data that clearly defines the challenges and serves as a grounding for future reasonable outcomes.  It is not enough to marshal human resources.  There must be an established organizational capacity, processes, and oversight to ensure that the human effort translates into a highly coordinate and effective service result.

The social, economic and political challenges accompanying our rapidly changing and fundamentally transforming global environments have created unique social challenges that demand cross sector solutions.  These new models of collaboration are uniquely evolving and being shaped by the transformational forces at work in our modern society which demands both competency and equity.

In pursuit of these new partnerships in the health sector, there should be a bias toward action, early organization and prevention, health consumerism and relationship based care, elimination of health disparities, and an integrated vision of health as the leading edge of development with an emphasis on sustainability.

Government, business, academics and non-governmental organizations are increasingly overlapping in the areas of social purpose.  The ability to organize their varied and often complimentary skills and resources will significantly benefit society. Such collaboration will be increasingly necessary to address the health care needs of an increasingly interconnected global society.

Audit for the New Health Care Professional

Posted on | January 21, 2016 | No Comments

BHG360_header_tag2

Mike Magee

In the shift from old models of paternalistic, reactive and interventional care to anticipatory, team-based, inclusive preventive care, health professionals need to think more strategically about their roles as leaders of the health delivery team.

What is health really but the maximization of human potential? How do we best connect patients to information, community resources, extended family and each other? What are the social determinants of health, and what are the quality of these resources in your own patient catchment area? Who is taking the family lead in each of the families you care for, and how could this person become enfranchised as a member of your care delivery team? And finally, what is your care philosophy, your strategy for delivering high quality humanistic care?

Beginning January 27th, I’ve teamed up with BHG360, a leading provider of healthcare financial solutions. The 5-part series to appear on the BHG360 site is a personal audit for the modern, progressive health professional, designed to consider and improve the fundamental underpinnings of a successful, holistic, preventive health care practice. The series includes:

  1. “The New Patient – Health Professional Relationship: Wellness Walking describes the latest research regarding the power of the patient-physician relationship and its role in forming social capital in healthy societies. Three growth areas for clinicians are highlighted – active listening, joyfulness and role modeling.”
  1. “Health Information Technology: An Underutilized Resource makes the case for health information technology as a humanizing force in health care. Clinicians are provided five questions to explore whether their attitudes toward technology are progressive and constructive.”
  1. “The Role of a Home Health Manager: Inclusion in the Health Care Team considers a modern approach to all of the human resource aspects of family health care. It defines health as human potential; considers the emergence of 4 and 5 generation families with competing needs and limited resources; and advocates for active inclusion of a lead family member (Home Health Manager) as an active member of the health care team.”
  1. “Roadmap to Health: Integrating Community Resources explores the role of community resources in the modern practice of preventive health care. The reader is introduced to Robert Wood Johnson Foundation’s ‘County Health Rankings & Roadmaps’ which allows practices at any location in the U.S. to explore what community resources are available to their patients and how their patient population ranks statewide on a range of public health outcome measures.”
  1. “The Secrets of Humanistic Care explores the basics of team-based, humanistic care. Using a NICU team as an example, the principles are applied to outpatient settings with a focus on inclusion, knowledge and accessibility.

Take a moment to visit BHG360 and review their unique offerings.

Can A Damaged Heart Heal Itself? With a Little Help, Maybe.

Posted on | January 13, 2016 | 1 Comment

F1.mediumSource: AHA Journals

Mike Magee

At last night’s State of the Union address, President Obama placed Vice President Joe Biden in the command seat as director of the scientific assault on cancer. The destination – a cure for the dreaded and stubbornly complex myriad of disorders that have created so much suffering and loss of life. Near equal as a plague has been cardiovascular disease, and especially heart attacks and strokes. In this arena, we may be getting closer to the promised land.

We’re all familiar with the idea of a “heart attack”. Most know the cause is obstructed blood flow through the coronary arteries to the heart muscle. Most also can tell you that heart muscle dies, turns to scar, and as a result the “heart pump” doesn’t work as well, often leading to disability and early death.  But what actually happens on a cellular level, at the time of the heart attack, and in the recovery period?

An article in the New England Journal of Medicine this week addresses these questions. Here are a few of the insights:

1. Cardiomyocytes, contracting heart muscle cells, are the cells we lose with a heart attack.

2. The interruption of blood flow not only damages these cells, but is also responsible for a measurable decrease in a natural chemical called follistatin-like1 (FSTL 1) produced in the outer layer of the heart or the epicardium.

3. Heart muscle cells aren’t known for their rapid cell division. In fact only 1% undergo cell division each year. They speed up a bit when there is a heart attack, but not enough  to allow repair.

4. In the past decade, researchers have tried to infuse adult stem cells into ischemic cardiac scarred areas, in the hopes of increasing the number of healthy cardiomyoctes in the damaged area. These attempts have largely failed to get the cells to stick to the injured areas where they are needed, and when they have stuck, the stem cells have often refused to differentiate or transform into cardiomyocytes.

5. It turns out that the heart does possess in its outer layer a group of endocrine like protein chemical stimulators that possess the ability to naturally enhance cardiomyocyte survival if blood flow is restricted, and also stimulate small vessel growth to help deliver additional oxygen to the ischemic areas. These are called “cardiokines”, and FSTL1 is one of them.

6. Surgical suturing of an FSTL1 infused patch onto an ischemic cardiac scar in mice has successfully induced reparative growth of cardiomyocytes in the damaged area.

7. How FSTL1 actually works, the intermediaries and number of steps, remains to be fully elucidated. The mice researchers are also looking at amphibians which have the ability to regenerate their own hearts for clues. But clearly, for the many individuals who have suffered major heart attacks and survived, only to face eventual failure of their heart pumps, with heart transplant then the only option, there is hope.

Lewin Report: “Uh Oh – Health Care Costs Are Skyrocketing Again!”

Posted on | January 11, 2016 | No Comments

lewin2

Jack Lewin

Health care costs went up by over 5% in 2015 after a mind boggling 7-year run of relatively flat costs.  But in 2016 — and for the next few years — the annual increase is thought by CBO and others to be 8% or more. Private insurance and even the new Affordable Healthcare Act (ACA) “exchanges” may be increasing as much as 15% this year. That’s ugly for patients, businesses, and government.

 

The GOP will blame rising costs on the ACA. Same cause for global warming? The US Senate in late 2015 for the first time sent a bill to repeal the ACA. And Paul Ryan sent a similar House bill to Mr. Obama this week. Yawn. C’mon, the House has done that 63 times😬. Obama killed the Senate Bill and Ryan’s latest bill and the ACA lives on; but there are some worrisome new storm clouds forming. Congress quietly buried in the December omnibus budget bill the delay of two ACA taxes that were to go into effect. One, the “Cadillac tax,” a tax on employers and employees for high cost insurance policies, was opposed by business and labor, and thus by both R’s and Dem’s. Like another unpopular provision of the ACA called the IPAB (Independent Payment Advisory Board—a powerful cost cutting body), I doubt if the ACA’s Cadillac Tax will ever go into effect. But, these delayed issues will somewhat undermine the ACA’s cost-saving capacities as costs are starting to rise again.

 

Dems realize the ACA didn’t manifest as a divine tablet, but they appreciate its value, with 15 million more Americans insured, fully funded prevention coverage, and many other positives. But they – especially Bernie Sanders – instead blame recent cost increases on insurers and on rising drug costs and profits. Hillary also believes the rise in drug costs is alarming – and it is. But, the proliferation of new biologic and ‘personalized’ drugs are therapeutically amazing, even though increasingly unaffordable. Yet so far, the percentage of pharmaceutical costs to total health costs hasn’t yet risen much (because all costs are rising). But patients cannot afford their share of these drugs, nor can state Medicaid programs.

 

Scientific progress is stunning, and the population is aging. Costs are going to go up. The NY Times this week highlighted the Kaiser Family Foundation recent study revealing that even insured people are increasingly being bankrupted by their out-of-pocket health care costs. Yes, health care is going to be even more unaffordable in the years ahead, unless…….. ?

Unless our next President and the Congress chart a new course (hold our breaths?). Well, President Rubio (my guess as to the R nominee) or President Cruz or President Paul Ryan (could be also!) would all change Medicare from an entitlement to a voucher-based income-indexed concept, shifting more costs to consumers over time. They would all also cap state Medicaid funding. These moves could definitely save government money, but make affected patients very mad (and oops– Medicare patients vote). These guys would also kill off the ACA, which would NOT save money (quite the contrary).

 

But, wait. What would President Trump do? Build a wall around Medicare? (J) No, but he thinks (along with his Vice President Sanders?) that Canada’s single payer model works remarkably well! Hmm.

 

So, what do I predict? OK, I predict we as a nation – in the nick of time – will finally take bold action to curtail rising health care costs. Of necessity. We will. Otherwise, health care will vampirise everything else in the economy from wages to business viability. Only one thing mentioned above among the potential candidate platforms might actually make our system much more efficient: a single payer or Medicare-for-all concept designed to drastically reduce administrative costs and also require that hospital and drug costs be negotiated down by an 800 pound gorilla.

 

But that isn’t politically viable…yet. And, I predict that a US single payer would be different from Canadian and EU models, and we would retain private insurers and private physician groups and hospitals –patients want and deserve choices—but choices that will be working in competition to achieve lower costs and higher quality around standardized benefits and more uniform charges for services. Some people call this approach an ‘all-payer’ model. Whatever we call it, I predict it’s coming.

 

The other positive (but very controversial) transition that is happening already across about one-third of US health care is that payment is rapidly shifting from paying for units of service (volume) to paying for value (better outcomes at lower costs). The ultimate and probably only viable and demonstrated way to accelerate paying for value is when doctors and hospitals are paid by ‘capitation,’ meaning they must form groups and networks that receive a fixed global budget for the patients they care for. This is how Kaiser Permanente and Geisinger and many large systems are currently paid. This is how Medicare Advantage largely works today. This is what is already happening more commonly in California and the western states than in the eastern and southern states.

 

But yes, capitation is destined to increase. Many physician colleagues and hospitals hate and resist that concept (equated by many to medical Communism), and I may have to enter the witness protection program for predicting it, but without this shift to incentivize value based payment concepts, we will never contain rising costs effectively. Never. And, it pretty much puts Dr. Wellby right out of business. But Dr. Wellby could join a group, or decide to become a concierge cash-only doctor. CAPG, the California-based national association of physician groups, added 35 very large groups across the country to its already impressive membership in 2015 —and all of them are capitated medical groups. The trend is growing.

 

So what does all of this mean to you and me as patients? It means we will increasingly choose branded and largely capitated medical groups and systems (like Mayo, Cleveland, Kaiser, university systems, and many others), but within the medical group or system we will hopefully still choose our own personal physician and/or specialist. We will also increasingly choose where to receive our care based on credible evidence of improved quality, fair cost, and higher patient satisfaction. The future will ideally still value the patient-physician (clinician) relationship and the best science over the dollar, but a viable future will have to be different from the status quo. To enable health care to be better, more affordable, and accessible to all, big change must happen. Actually, it’s already in process, even if a lot of folks aren’t too happy about it.
My hope is that doctors, clinicians, and consumers (patients) will participate together in preserving what is good about our current non-system in terms of choice and quality while effectively addressing the growing cost dilemma.

_____________________________________________________________________________________

 The Lewin Report represents the personal thoughts and reflections of health policy, science advocate, and would-be futurist Jack Lewin, M.D., President and CEO of the Cardiovascular Research Foundation; Chairman of the National Coalition on Health Care; and former chief executive of the American College of Cardiology, the California Medical Association, and the State of Hawaii’s Department of Health and its public hospital systems. Comments as desired to jlewinmd@gmail.com

The Risks and Benefits of Home-Centered Deliveries in America.

Posted on | January 1, 2016 | No Comments

db144_fig1CDC, 1990-2012

Mike Magee

In the final week of 2015, there was a great deal of coverage on the relative risks of home delivery versus hospital-based delivery in the United States. The coverage derived from a NEJM study of Oregon databases in 2012 and 2013 that listed the intended site for delivery for all births for the first time. This allowed for a comparison of deaths rates and Apgar scores. The study was augmented in this week’s NEJM with a case study and an editorial.

The issue is a complicated one, made no more discernible by comparisons to the UK obstetrics approach, which more heavily emphasizes home deliveries, but also maintains a higher level of integration between out-of-hospital and in-hospital systems. Translation: they are better prepared to support their home based program and better able to access hospital settings for emergent problems should they arise during a home delivery.

At the core of the debate are the risk/benefit profiles of these two very different settings for delivery. What are the facts as we know them?

1. Thirty five years ago, the risk of death at hospital delivery for a single baby was approximately 1 in a thousand, and the Caesarean rate was 15%. Today, the risk is roughly the same, and the U.S. Caesarean rate has more than doubled.

2. In the current study of Oregon women in 2012 and 2013, the Caesarean rate of women who had chosen home-delivery as their primary option was 5.3%. For women who chose hospital delivery, it was 24.7%.

3. The Oregon study included 75,923 planned and completed hospital deliveries, 1968 completed home births, and 1235 completed free-standing birth-center deliveries. Unplanned home births were excluded and only singleton, term, normally developed fetuses in cephalic presentation were included in the analysis.

4. Comparisons of fetal death were based on “intended site” of delivery, not on where the delivery actually took place. Thus, a labor that began at home and ran into trouble requiring emergency transfer to the hospital fell into the “at-home” category.

5. Comparing those who intended a home delivery with those who intended hospital delivery, there was a statistically significant higher rate of fetal death in the at-home group – 1.8 per 1000 for planned hospital births versus 3.9 per 1000 for planned out-of-hospital births. That risk was conuter-balanced by risks associated with the more than four-fold increase in C-section rates among women chosing a hospital-based birth.

6. Approximately 16% of women who intend a home-based birth require emergency transport to a hospital.

7. Wilbur’s NEJM case study succinctly summarizes the complex pro’s and con’s for those chosing home deliveries with these words: “Cesarean delivery imposes substantial risk, including a rate of serious maternal complications and death that is three times as high as the rate with vaginal delivery, even among low-risk women. In addition, one in four women giving birth in a hospital report feeling overwhelmed, frightened, or anxious. The consistent, one-on-one support of a home-birth attendant and the familiar environment of the home may improve the experience for some women. However, even in the patient who is at lowest risk, unpredictable events can occur during labor, and immediate access to an operating room and a neonatal resuscitation team could improve outcomes.”

Where is there consensus? All parties appear to agree that their are risks and benefits to both approaches. For the U.S., that likely means the growth of hybrid models and a better trained and accessible goup of home-based birth support professionals as well as greater integration (as exists in the UK) to allow emmergency access to hospital settings if required.

Michael Millenson on How To Make Medical Errors Less Profitable.

Posted on | December 22, 2015 | No Comments

M_MillensonNew120

Michael Millenson’s column in Forbes last week drew attention to the profitability of hospital errors, and attempts to interrupt the perverse cycle. In his words, “…the push for safer care has had much less urgency and been much less far-reaching than it can or should be. Perhaps the latest results of the HHS-hospital partnership herald a new patient safety culture finally taking hold. That’s a nice thought this holiday season. Meanwhile, it remains critically important to support better data collection, greater transparency of individual hospital results and more focused purchasing by health plans, employers and consumers alike in order to reward those whose first priority is, truly, ‘first do no harm’.”

You can find Michael’s entire article HERE.

keep looking »
Show Buttons
Share On Facebook
Share On Twitter
Share On Google Plus
Share On Linkdin
Share On Pinterest
Share On Youtube
Hide Buttons