Posted by on in NEJM Highlights

What are annual physicals for? Annual physicals are costly (~$10 billion annually) and have never been shown to improve outcomes, but people value them. In this dichotomy lies a lot of the inner tensions of medical care: between delivery of technical care, and nurturing of human relationships, and those are illuminated by two articles in counterpoint.  In the end though both sides come to a point of view that is not altogether dissimilar – that what is needed is not an annual physical, but some sort of preventive care/health review visit which, instead of being a fishing expedition for problems… Read More

Posted by on in Digital Health, Providers

A few problems Geographic barriers to the entry have long protected providers from best-in-class competition.  Provider consolidation – theoretically a logical response to the current operating environment — reinforces these barriers by locking up referrals and making systems too big / too few to fail.  Instead of pushing providers aggressively on value, payers and regulators may end up nursing underperforming systems (e.g. Highmark’s bail-out of the West Penn Allegheny system) and discouraging disruptive entrants for fear of unintended damage to the stability of the local provider infrastructure.  Even if consolidation is necessary for value-based care, the result looks like a leverage… Read More

Posted by on in Payers, Providers, Uncategorized

Summary In this working paper, we develop the following thesis. In the not so distant future (a decade or two), medicine will be largely governed by algorithms — highly deterministic clinical pathways characterized by a high level of reproducibility of care — that will be developed and improved by providers. These algorithms will include individual patient preference branch-points but not individual provider preference.  As a result, payers and providers will agree on coverage on the basis of a set of algorithms and a process of how they should evolve; providers will be paid on a fee-for-service basis for following the… Read More

Posted by on in Population Health, Providers, Uncategorized

Over eight months between October 2014 and June of this year, Ochsner formalized alliances with five major provider systems in Louisiana. The first wave (with St. Tammany Parish, Terrebonne and Slidell) reinforced Ochsner’s stronghold in New Orleans. The second wave (with Lafayette General and CHRISTUS) secured pathways to markets west along I-10 and the coast and northwest along the I-49 corridor to Shreveport. This collection of alliances — dubbed the Ochsner Health Network (OHN) — is effectively statewide with ~30% of the hospital beds and ~30% of the physicians. Key components of the alliances include: a joint clinically integrated physician… Read More

Posted by on in NEJM Highlights

Promise for systemic amyloidosis (and beyond?) Systemic amyloidosis is an uncommon disease in which abnormal cells (typically antibody-producing B cells) produce large amounts of protein that deposit as amyloid fibrils in various organs (heart, kidney, liver). These are the same kind of deposits that create plaque in the brain in Alzheimer’s disease.  In systemic amyloidosis, the deposits cause organ damage, failure, and death and treatment options are limited.  GSK is developing a monoclonal antibody directed at serum amyloid P (SAP), a naturally occurring glycoprotein that binds to amyloid fibrils. The attachment of the antibody to SAP which is bound to… Read More

Posted by on in Consumer Health, Payers, Providers

Summary A Portland-based urgent care operator is launching a health plan from scratch The strategy targets the busy and healthy with the convenience of a retail network providing “store brand care”; a simple, consumer oriented service model at low cost. Carving out this segment can plausibly allow for sustained advantage in admin, medical cost and revenue management. The plan has hit a speed bump with regulators on pricing, so evidence of this model’s market appeal will come slowly. Convenience care has historically played nice with the ecosystem, but Oscar’s explosive valuations may convince some to be more aggressive. Insurers may… Read More

Posted by on in NEJM Highlights

The emergence of a new approach to drug development in cancer Cancers are classified by the organ or tissue from which they arise, but as our molecular understanding increases, another level of categorization is emerging based on the molecular characteristics of the tumor. In a novel but sure to be growing approach, Roche/Genentech tested their drug vemurafenib (Zelboraf, currently approved for melanomas with the BRAF V600 mutation) in a study population that was largely agnostic to tumor provenance as long as it was BRAF V600 positive. 122 patients were enrolled with more than half a dozen cancers represented –… Read More

Posted by on in Providers

In a recent study, Ryan, Shortell, et al analyzed the composition of PCP compensation (broken down into salary, productivity and quality/other components) across practices with ACO contracts vs. those with more traditional business models.   This note will: provide a quick summary of results offer an alternative interpretation of the data describe two methodological points regarding the data set The major finding As of 2012/2013, there are no major systematic differences in how PCPS are paid in ACO practices vs. others.  Whether in an ACO or not, PCPs were paid on average ~50% on salary, ~45% on productivity and 5%… Read More

Posted by on in NEJM Highlights

Palbociclib – first to target cyclin dependent kinases – breast cancer As all biology majors know, cyclin dependent kinases are critical elements controlling the machinery of cell proliferation.  They have proved difficult targets due to their ubiquitous activity in both normal and abnormal tissue – until now. In a phase 3 study, about 500 patients with metastatic hormone positive, Her2 negative breast cancer were treated with palbociclib (Ibrance, Pfizer, recently FDA approved) vs. placebo.  The median disease progression time for patients on drug was 5 months longer than for placebo (9 vs. 4 months, survival data was pending).  Adverse effects… Read More

Posted by on in NEJM Highlights

Interventionalist treatment for stroke: In the 80s and 90s, treatment of myocardial infraction was greatly advanced by the introduction of systemic clot busting drugs (t-PA and others); further advance occurred in the 90s when it was shown that immediate cardiac catheterization produced even better results. Acute embolic stroke has followed the same path – in the 90s, it was shown that t-PA treatment within 3 hours of onset of symptoms was beneficial, and ever since there has been a move toward treatment modalities where an interventional radiologist acts on the clot directly. Two randomized controlled studies now show unambiguously that… Read More