Posted by on in NEJM Highlights

“My name is T-Cell…, James T-Cell” Immune T-cells are licensed to kill other cells through a quick molecular kiss of death, and as such are potentially powerful allies in controlling a tumor. For obvious reasons this killing power is under strict regulatory control and in particular T-cells display PD-1 proteins on their surface, which when engaged by the ligand PD-L1 on another cell, protects that cell from being killed. Tumors often display high levels of PD-L1 so that disrupting the interaction between PD-L1 and PD-1 can enhance the effectiveness of immune killing of tumor cells. Amplifying results from last year … Read More

Posted by on in NEJM Highlights, Providers

I am not sure how many docs continue to do this, but I still read the actual hard copy of my NEJM, and that means I flip past ad pages with smiling grandfathers playing with grandchildren thanks to supercalifragilistic products on my way to scholarly papers with tables and figures.  But this time, I stopped in puzzlement when I came across exhibit 1; Intermountain is a health system based in Utah, very highly respected for its sound approach to quality and cost control[1], but not broadly well known for cancer care in the way of centers like Dana Farber … Read More

Posted by on in Population Health, Providers

It is a long-standing hypothesis shared by many providers that community-based interventions that improve primary care could lead to overall healthcare savings by preventing (or delaying) the occurrence of medically expensive conditions.  Rigorously proving this has been difficult, and only a few appropriately controlled studies have been published. In a Letter to the Editor of the American Journal of Managed Care[1], my colleague Alex Brown and I commented on an earlier article[2] evaluating the impact of a community health … Read More

Posted by on in NEJM Highlights

RBRVS: an acronym we ought to think more about RBRVS stands for the Resource Based Relative Value Scale, and codifies the time and effort involved for a comprehensive set of physician activities on which Medicare payments are based. In this perspective, the authors highlight that most value-based payment (VBP) systems currently under development are essentially built as modifiers on top of the RBRVS. But the RBRVS has two major issues with it: it is “downward sticky” and has not evolved to take into account increased efficiency (e.g. automation), and it underestimates E/M (Evaluation/Management) activities which have become more and more … Read More

Posted by on in NEJM Highlights

Could Uber happen to healthcare? A Perspective article that points out that the success of Uber is rooted in the flaws of an industry where customer convenience and value for money took the backseat to the interest of a set of service providers highly protected by regulation. Sounds familiar?  Obviously, the regulatory moats of healthcare are much wider and deeper, but in a curious mix of warning (watch out!) and encouragement (this will be good for you if you embrace it!) the authors argue that the medical profession should not consider themselves immune from the disruption that has affected … Read More

Posted by on in NEJM Highlights

Systems biology finally gets real: an unexpected use for a diabetes drug Chronic Myelogenous Leukemia (CML) has been the poster child first for a disease with a precise genetic cause (the Philadelphia chromosome), and then for targeted drug design (with imatinib – Gleevec). Unfortunately, few patients achieve a complete response to therapy which means that they have to stay on drug indefinitely. This commentary highlights recent research which shows that pioglitazone (Actos), an approved diabetes drug that activates a specific cellular pathway (STAT5) can synergistically enhance treatment with Gleevec to achieve a potential cure.  While this particular work affects only … 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 Providers

The build-out of the Cleveland Clinic and Mayo branded networks continues apace. Most recently, the Virginia Hospital Center joined the Mayo Clinic Care Network in March and Sequoia Hospital (Dignity), Piedmont Healthcare and Valley Health System (NJ) signed up with Cleveland Clinic this past March and early April. Growth of the networks and current snapshot These four deals cap torrid growth in the networks especially in 2013 and 2014. As of the end of the first quarter of 2015, Mayo has affiliations with systems totaling 13.4K beds (and a rough estimate of 14K employed physicians) while the Cleveland clinic … Read More

Posted by on in Providers

If value-based care broadly delivers on its promise to reduce hospital admissions by providing more timely ambulatory care, a lot of today’s bed capacity will end up redundant and stranded. How can we navigate to a new equilibrium? Recent developments in the New Orleans area (whose population size still has not recovered from Katrina and is potentially therefore a model case of oversupply) may offer some window into future endgames for resolving the supply-demand imbalance. Acquire, unbundle, and selectively shut-down One approach is for an integrated system to acquire ailing assets, keep the viable services, and, for the rest, … Read More

Posted by on in Providers

Summary Boeing is creating a benefit design model which sets up providers to compete for their book of lives via provider-branded narrow networks By offering a choice among competing narrow and full network products, the model may make narrow networks more palatable for employees Narrow networks can produce a volume windfall for providers (e.g., share gain, leakage reduction) and profits from better care management and a risk deal  Providers “pay” for the narrow network opportunity by being lower cost (often via incremental discounts) in hopes that these gains outweigh cannibalization (profits lost on current patients who transition to the narrow … Read More