Cure for Cancer: It’s Elementary, My Dear Watson!

“Excellent!” Watson said.

“Elementary, “ said Holmes.

Sir Author Conan Doyle (1859-1930), The Crooked Man

Sherlock Holmes never said, “Elementary, my dear Watson!” But never mind.

What’s important is the gist of what he said and what’s happening now. Fourteen major cancer centers have teamed up with IBM’s supercomputer, Watson, to pursue and win the race against cancer. And it’s always a race, to kill the cancer before the cancer kills the patient.

And why not? If IBM’s Watson can win at chess against the world’s best chess masters and beat Jeopardy winners, why not try to cure cancer by near instant analysis of the a cancerous tumor’s genome and scouring of the world’s medical literature to find out what works ? Why not use “cognitive computing” to solve cancer’s mysteries? Why not treat IBM’s Watson as a “capable and knowledgeable colleague ,” to use an IBM’s executive phase?

Finding the answers to these question is the basis for a statement in President Obama’s statement in his January 20, 2015 State of the Union address.

“Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes – and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”

In the words of Francis Collins, M.D., Ph.D, of NIH, and Harold Vrmus, M.D. of the National Cancer Institute,

“With sufficient resources and a strong, sustained commitment of time, energy, and ingenuity from the scientific, medical, and patient communities the full potential of precision medicine can ultimately be realized to give everyone the best change at good health” ( “A New Initiative on Precision Medicine,” New England Journal of Medicine,” February 26, 2015).

And while we’re waiting fo the cure, keep these words in mind “cognitive computing,” “DNA-genetics,” and “personalized precision medicine.” The words may signal the future of health care. And with the help of 14 major cancer centers, it may become a reality quicker than you think.

ER Visits Climb Under ObamaCare

The best laid schmes o’ mice and men

Gang aft a’gley

Robert Burns 1759-1796, To a Mouse

It wasn’t supposed to be this way. Under ObamaCare, more people would be insured, and they would no longer have to go to the ER. They could go to their primary care physician and skip those notoriously overcrowded ERs.

It hasn’t worked out that way. According to a report of The American College of Emergency Physicians, 2,099 of the doctors said ER visits are at an all time high: 28% reported visits have greatly increased, 47% slightly increased, 17% the same, 5% slightly decreased, and 0% no change.

Federal policy makers overlooked a number of crucial factors, as seen through the eyes of patients.

· 1. A growing shortage of primary care physicians with overloading practices in those who remain.


· 2. Delays, sometimes for weeks or months, in scheduling a primary care or specialist visit.


· 3. A tendency among medical practices to being open only during working hours and closed on weekends.


· 4. Public knowledge that hospitals were legally obligated to be open 24 hours a day and to receive and treat all comers.

· 5. An understanding among patients that ERs had the equipment and the spectrum of specialists to handle almost any contingency.


· 6. The trend among primary care physicians to not accept or to see fewer Medicare, Medicaid, and uninsured patients.


· 7. The historical pattern of uninsured or under-insured patients to go the ER first because that is what they had always done.


· 8. The insensitivity of insured patients to costs because they believe their insurance will pay no matter what the cost.

· 9. The belief that when it comes to one’s health or one’s illness or complaint, money is no object.


· 10. The reality that were no financial or economic penalties for not going to the ER.



· 11. The false promise of ObamaCare – that if you had a Medicare, Medicaid, or health exchange plan that if you went in these programs, you had access to primary care physicians.


The spikes in ER visits ran counter to one of the goals of the health reform law. The law was designed to reduce pressure on ERs by getting more people insured through Medicaid or subsidized private coverage and providing better access to primary care (Laura Ungar and Jayne O’Donnell, “Contrary to Goals, ER Visits Rise Under ObamaCare,” USA Today, May 4, 2015)

Twelve Obama Messes

Critics are having a field day itemizing the messes President Obama may leave behind when he leaves offices. Democrats retort these messes can be traced to the depth of 2008 Republican recession, the GOP’s unwillingness to cooperate with the President, and negative global economy and terrorism, both of which are bey9=ond Obama’s control.

Whoever is responsible in this blame shifting exercise, these messes loom on the 2016 horizon.

One, if the Supreme Court rules against federal subsidies in June , Republicans will have to find a way humanely deal with the estimated 6.5 to 7.5 million who would lose their subsidies.

Two, those who don’t comply with the individual mandate and buy a health plan will have to pay an average penalty of $1,130.

Three, the ObamaCare policy that all plans must include 10 essential benefits raises premiums and deductibles for the non-subsidized.

Four, new more expensive policies meeting ObamaCare compliance standards will require more people to go onto subsidies.

Five, employers will place more employees on part-time to avoid $2000 penalties for not covering employees.

Six, the U.S. economy has experienced low economic growth, barely over 2% since the recession ended, compared to all previous recessions since World War II, in which GDP growth averages 3% to 5%.

Seven, the job participation rate is the lowest since 1978.

Eight, the quality of jobs has plummeted, with 6.6% now working part-time, a 46% rise since 2007.

Nine, the number of small businesses closing, merging, or declaring bankruptcy exceeds the number of new business startups.

Ten, the size of the average paycheck has gone from $54,059 to $51,838 during the Obama presidency.

Eleven , the national debt continues to balloon, with the magnitude of the Obama debt exceeding that of all previous presidents combined.

Twelve, lack of entitlement reform may result in these federal programs running out of money: Social Security Disability Trust in 2016, Medical Hospital Trust 2030, and Social Security and Survivor Trust 2032.

Sources

Grace-Marie Turner, “Cleaning Up ObamaCare and Other Obama Messes, “Forbes, April 28, 2015.


Karl Rove, ”The Messes Obama Will Leave Behind, “ Wall Street Journal, April 30, 2015.

The ObamaCare Story: A Work in Progress

I’ve been working on a book The ObamaCare Story, based on 2500 Medinnovation blogs I’ve written over the last 6 years.

It’s a hard book to write. There’s no beginning and no end. Health care inequities were brewing before Obama became president, and inequities will not end with the Supreme Court decision on the legality of federal subsidies in late June, or when Obama finishes his second term. Individual inequities, deemed “social injustices” by some, are part of the human condition. Always have been. Always will be. To paraphrase George Orwell, some people are more equal than others.

With an ObamaCare book, there is too much to think about , too much to write about. There are too many unanswered questions. too many failed solutions, too many philosophic and ideological points of view.

Is a compassionate socialistic government the answer? Not if you consider Europe’s economic stagnation, or the inner city riots after we pumped $22 trillion into the war of poverty since 1965. Is unbridled American capitalism with attendant prosperity the solution? Not if you consider the fact that 30 million Americans remain uninsured. Quasi-socialism, ObamaCare style, isn’t working very well, if you ask the American middle class. And quasi-capitalism, Republican style, has yet to be tried for health care and is met with massive skepticism on the left.

The upcoming June Supreme Court decision illustrates the problem. If the court affirms ObamaCare’s right to subsidize the poor and quasi-poor, controversies over the unworkability of the health law with its redistribution of wealth and soaring national debt will continue. If the court rules against federal subsidies, what will the Republicans do about those 7.5 million poor folks left without subsidies? Extend the subsidies? Replace the subsidies with tax credits? Lower taxes for all and hope a resurgent economy with more federal revenues will repair the safety net and finance the have-not’s?

There are other unanswered questions as well.

Will technology, which has upended the economy and arguably contributed to unemployment by replacing humans with machines save us from ourselves?

Will technologism replace humanism, or will they be complementary and supplementary?

Will mass aggregations of health care data show us the path to lower costs, higher quality, and better outcomes?

Will robots posing as doctors, telemedicin ‘s virtual visits be superior to real human- to-human physical visits with doctors?

Are doctors working in teams, backed by evidence-based algorithms, better than individual doctors using clinical judgment based on experience and real-time interaction with patients ?

Can patients, empowered by iphones and endless streams of on-line health information, be relied upon to make the right decisions for themselves?

Is government, even with its teams of policy experts and access to reams of population data, be trusted to guide the right decisions, at the right time, for the right reasons at the point of care of billions of patient-doctor encounters without violating the patient’s privacy or the doctor’s pledge of confidentiality?

Should health care be directed from the top-down, from Washington. D.C, or from the bottom-up, by those in the health care trenches or those in integrated health organization’s executive suites?

These are just a few of the tough questions that make the ObamaCare story so hard to write. The ObamaCare story and its sequel will always be a work in progress, a struggle between progressives and traditionalists, with no clear answers in sight. Is ObamaCare "fair for all", or is it merely a "free for all" fairy tale.

An Example of “Value” in Joint Replacements

"Value" is defined as the health outcomes achieved for patients relative to the costs of achieving them. It is the only goal that can guide strategy in health care, the only “true north” that can resolve the difficult choices organizations will need to take.

Michael Porter, Ph,D, and Thomas H. Lee, MD, “Why Strategy Matters Now,” New England Journal of Medicine, April 30, 2015

One of the functions of this blog is to make the abstract concrete by using examples. Translating the meaning of “value” in clinical affairs to a health care reality is such a function.

Reducing costs and improving outcomes of joint replacements in hospitals is such an example. How this can be done has been shown at Baptist Health System in San Antonio, which owns 5 hospitals. The system saved over $1 million in a year for hip and knee replacements by bundling Medicare payments into one reduced 3% payment covering everything from physician fees, to nursing, to anesthesiology fees, to post-op nursing home care to readmissions, to anything that happened within a month after surgery. If savings occurred, the hospital system and the orthopedic surgeons shared the savings. For a surgeon doing 35 procedures a month, this amounted to $21,000("An ObamaCare Payment Reform Success Story- One Health System, Two Procedures," Kaiser Health News, April 30, 2015).

These savings were achieved through a series of measures: standardizing the cost of artificial joint devices by selecting one joint device, lowering costs of blood thinning drugs and compression stockings, have post-op therapy performed at home rather than in nursing homes, getting patients active quicker, reducing use of physical therapists.

The results of these combined efforts, planned at joint meetings of hospital executives, nurses, and physicians – was shorter hospital stays, reduced use of nursing facilities, increased savings for Medicare, and profit-incentives through shared savings for the hospital system and orthopedic surgeons. There were losers as well – nursing facilities and physical therapists.

This is an example of what can be done through the combined efforts of a hospital organization and its providers. According to Michael Porter of Harvard Business School and Thomas Lee of Harvard Medical School, “A provider organization decides that it will compete for orthopedic patient volume by creating a tightly organized team(integrated practice unit) to deliver care in a lower-cost setting and by negotiating bundled-payment contracts with major employers and payers.” These payers and employers may be Medicare, insurers, or self-funded employers.

State Exchanges Struggle As They Await Supreme Court Decision

Because of balky IT technologies, expensive call centers, and slow enrollment, 17 healthcare.gov state exchanges are struggling to survive as they wait late June Supreme Court ruling on legality of federal exchanges. The 17 exchanges (16 states and D.C) include Washington, Oregon, Idaho, California, Nevada, Minnesota, Kentucky, Colorado, New Mexico, Massachusetts, New York ,Maine, D.C., Rhode Island, Connecticut, and Vermont. The state exchanges were supported by $5 million from the federal government, but those funds are run out. Of the 11.6 million enrolled in all healthcare.gov exchanges: 2.6 million came from state exchanges ( 12% growth) and 8.8 million were from federal exchanges (61% growth). If the court decides federal exchanges were illegal, and federal support is not forthcoming, the state exchanges will have a few options, including; one, continuing to support unsustainable state-run exchanges; and two, going out of business.

Source: “Nearly Half of ObamaCare Exchanges Struggle As Woes Grow,” Washington Post, May 1, 2015)