4 ms·

The money quote for me was this: “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a d

The money quote for me was this: “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a disruptive innovation. It just guts the current business model.” Wouldn't it be better if people never had to go into the hospital in the first place? Aside from the supplemental costs - "surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients." - consider the quality of life issues. If Medicare is concerned with scaling this program up from a couple thousand people, instead of completely cutting a program which has proven its ability to cut costs AND improve quality of life, why not try it with five or ten thousand people first? If that works, then try it with 20 thousand people, then 50 thousand. If it doesn't scale at that point, then cut it. Another possible solution is to find a way to eliminate the for-profit hospitals. But Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman.

DanBC 13y ago
Yes. For illnesses like diabetes it's best if you can prevent people getting it, but if they have it it's best if you can help them to avoid getting the complications. "Diabetic foot" sounds funny, until you realise that it kills people and is a reason for leg amputation. (Prognosis after such amputation wasn't great last time I looked, in about 2004.) Sending a real person in a car to visit someone at their home sounds intensive, and sounds expensive. Compare it to a tele-medicine device that takes measurements and sends those to a centre somewhere, with people calling over the phone. It's a shame that the evidence base appears to be being ignored. EDIT (after adestefan and ajtaylor commented) -- it feels expensive, but the evidence base is clear that it's not expensive because it works, where as the thing that feels cheap is wasted money because evidence shows it doesn't work. And it's a shame that people in charge appear to be ignoring evidence, and going by 'gut feeling', because it means effective interventions are not happening. I hope that mentioning the research that a decision is based on becomes more widespread. Even organisations that claim to be evidence based can make odd decisions.
- ajtaylor 13y ago
  I would agree with you as long as the devices you're referring to are completely automated and rely 0% on the person to do something. My grandmother didn't remember things so well as she got older, so without someone to help her to remember to take her medicine (or that she had indeed taken it) it would have had real implications for her health. As it happened, she had my mother and later my uncle to take the place of the nurse. In my limited experience, the key to seniors is to avoid having to rely on their memory. As for avoiding complications, I agree with you. The best action is to avoid the disease, and then to avoid the effects of the disease. As mentioned in the article, sending a person in a car to visit someone is obviously more expensive than a phone call. But the nurse's visit can help to avoid a problem which requires a far more expensive visit to the hospital. That is where the cost savings come into play.
- adestefan 13y ago
  There is something special about having that physical person with you, in your home, talking to you one on one. Yes it's somewhat expensive up front, but the human contact is a major component of what makes this a success. There is one extra photo in the print edition of this story. It's the nurse, Ms. Graefe, hugging Mr. Bradfield in his kitchen.
  - Evbn 13y ago
    Because much of our health needs are mental, and much of mental health is social. Living alone is a chronic debilating condition, akin to diabetes. Live with your parents, and later live with your kids. Or outsource to home aides.
davidp 13y ago
That quote was the zinger for the article for me too. But electrifying claims like that one should automatically be received with a healthy amount of skepticism; I was disappointed that the author presented the quote bare without any balancing commentary or promise to validate the claim. If the claim is true it's revolutionary; if it's false or exaggerated, it substantially reduces the credibility of the speaker. In the latter case, this article's credibility would itself be weakened. Hence my disappointment.
pekk 13y ago
The article suggests that this measure is only opposed by healthcare incumbents, because it threatens their profits. The comments also show a critical source of opposition that the article doesn't mention: political anger about 'entitlements'. Many or perhaps even most Americans actually won't agree that it's better if people don't have to go into the hospital in the first place - if they understand that the way of getting that is to offer more care to people at taxpayer expense - even if the expense to taxpayers is actually less. It's unjust or unfair, you see, because the other guy is getting something for free and his children should be paying for the nurse to come by once a month, not me. As an ordinary "main street" American, maybe I would rather see him denied that preventive care, even if it means higher costs in the end, in order to avoid the loathsome outcome that I am paying part of his bill. I'd really rather not pay for his emergency care either (and some comments in this thread have suggested the same, that we will save more money by not at all covering people who are at risk), but that's hard to push politically. So we will pay for expensive emergency care, because we don't really have a choice. But we'll be damned if we'll pay for preventive care which doesn't seem urgently necessary.
- ajtaylor 13y ago
  But isn't eliminating preventative care like shooting yourself in the foot? Or cutting off your nose to spite your face? My parents are in their 60's and definitely complain about the "system" and the entitlements people feel they deserve. But I feel certain that if they were shown the numbers, which showed that giving "free" preventative care at a cost to taxpayers of $x, but would prevent emergency care at $x * 10, they would agree that the preventative approach is better. But as you say, this is a hard sell politically. All this reminds me of the famous quote from Jerry Maguire: "Show me the money!" Is there anything wrong with pandering to people's base desires, namely "If the government spends less money, we can lower my taxes without implications"?
skue 13y ago
> Another possible solution is to find a way to eliminate the for-profit hospitals. Oh God, no. Did you read that incredibly-long and incredibly-powerful healthcare article by Time? Non-profit hospitals are among the worst offenders. http://www.time.com/time/magazine/article/0,9171,2136864,00.html http://www.time.com/time/magazine/article/0,9171,2136864,00.... (subscription) Some of the most innovative hospitals are actually for-profit. Here's another great article by Atul Gawande comparing Steward Health System, which was founded by Cerberus Capital, to the Cheesecake Factory (but in a good way): http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_... > Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman. As an entrepreneur, I agree that it's a tragedy that HQP is being abandoned instead of scaled. But ACOs will absolutely have a financial incentive to keep patients out of the hospital and hire companies such as HQP. The problem is that this transition has yet to occur, so HQP is ahead of the market. Hopefully they can find smart investors in the meantime (perhaps this article will help).
- ajtaylor 13y ago
  I don't doubt that there are excellent for-profit hospitals. Chances are I've even used the services of one. One can find good things coming out of nearly every kind of business if you look hard enough. Please don't take the suggestion as anti-capitalist, because I'm not. My argument against them is simple: it's very hard to align the two goals of 1) making as much money as possible and 2) providing the best care possible, which in my mind means making their stay as short and inexpensive as possible. Even as a youngish person (late 30's), I don't want to go in the hospital at all and if I do have to go I want to be in and out as soon as it is safe to do so. The ultimate goal is to keep people as healthy as possible, and to spend the least amount of money to do so. This requires finding the right balancing point, but I'm positive it can be done if the political will exists.
  - jacoblyles 13y ago
    > "I'm positive it can be done if the political will exists." In your lifetime, what major problem had the political will existed to solve it? As Moldbug says, we have a large government, but not a strong one.
roguecoder 13y ago
We already sort of had that in Massachusetts. For hospitals that treated large numbers of free care patients were given flat grants to cover operating costs. ("Free care" covers people too poor for health insurance or to pay for treatment and too young, childless, employed, healthy, etc. for Medicaid.) However, it is politically unfeasible, because people can't see what the money is being spent on and it was eventually eliminated to "save money". Even though local hospitals had created programs that helped lower costs and provided better care to populations normally ignored. People care more about punishing poor people than they do about saving taxpayer's money. Otherwise drug testing for medicare recipients wouldn't be a thing.

DanBC 13y ago

Yes. For illnesses like diabetes it's best if you can prevent people getting it, but if they have it it's best if you can help them to avoid getting the complications. "Diabetic foot" sounds funny, until you realise that it kills people and is a reason for leg amputation. (Prognosis after such amputation wasn't great last time I looked, in about 2004.) Sending a real person in a car to visit someone at their home sounds intensive, and sounds expensive. Compare it to a tele-medicine device that takes measurements and sends those to a centre somewhere, with people calling over the phone. It's a shame that the evidence base appears to be being ignored. EDIT (after adestefan and ajtaylor commented) -- it feels expensive, but the evidence base is clear that it's not expensive because it works, where as the thing that feels cheap is wasted money because evidence shows it doesn't work. And it's a shame that people in charge appear to be ignoring evidence, and going by 'gut feeling', because it means effective interventions are not happening. I hope that mentioning the research that a decision is based on becomes more widespread. Even organisations that claim to be evidence based can make odd decisions.

ajtaylor 13y ago
I would agree with you as long as the devices you're referring to are completely automated and rely 0% on the person to do something. My grandmother didn't remember things so well as she got older, so without someone to help her to remember to take her medicine (or that she had indeed taken it) it would have had real implications for her health. As it happened, she had my mother and later my uncle to take the place of the nurse. In my limited experience, the key to seniors is to avoid having to rely on their memory. As for avoiding complications, I agree with you. The best action is to avoid the disease, and then to avoid the effects of the disease. As mentioned in the article, sending a person in a car to visit someone is obviously more expensive than a phone call. But the nurse's visit can help to avoid a problem which requires a far more expensive visit to the hospital. That is where the cost savings come into play.
adestefan 13y ago
There is something special about having that physical person with you, in your home, talking to you one on one. Yes it's somewhat expensive up front, but the human contact is a major component of what makes this a success. There is one extra photo in the print edition of this story. It's the nurse, Ms. Graefe, hugging Mr. Bradfield in his kitchen.
- Evbn 13y ago
  Because much of our health needs are mental, and much of mental health is social. Living alone is a chronic debilating condition, akin to diabetes. Live with your parents, and later live with your kids. Or outsource to home aides.

davidp 13y ago

That quote was the zinger for the article for me too. But electrifying claims like that one should automatically be received with a healthy amount of skepticism; I was disappointed that the author presented the quote bare without any balancing commentary or promise to validate the claim. If the claim is true it's revolutionary; if it's false or exaggerated, it substantially reduces the credibility of the speaker. In the latter case, this article's credibility would itself be weakened. Hence my disappointment.

pekk 13y ago

The article suggests that this measure is only opposed by healthcare incumbents, because it threatens their profits. The comments also show a critical source of opposition that the article doesn't mention: political anger about 'entitlements'. Many or perhaps even most Americans actually won't agree that it's better if people don't have to go into the hospital in the first place - if they understand that the way of getting that is to offer more care to people at taxpayer expense - even if the expense to taxpayers is actually less. It's unjust or unfair, you see, because the other guy is getting something for free and his children should be paying for the nurse to come by once a month, not me. As an ordinary "main street" American, maybe I would rather see him denied that preventive care, even if it means higher costs in the end, in order to avoid the loathsome outcome that I am paying part of his bill. I'd really rather not pay for his emergency care either (and some comments in this thread have suggested the same, that we will save more money by not at all covering people who are at risk), but that's hard to push politically. So we will pay for expensive emergency care, because we don't really have a choice. But we'll be damned if we'll pay for preventive care which doesn't seem urgently necessary.

ajtaylor 13y ago
But isn't eliminating preventative care like shooting yourself in the foot? Or cutting off your nose to spite your face? My parents are in their 60's and definitely complain about the "system" and the entitlements people feel they deserve. But I feel certain that if they were shown the numbers, which showed that giving "free" preventative care at a cost to taxpayers of $x, but would prevent emergency care at $x * 10, they would agree that the preventative approach is better. But as you say, this is a hard sell politically. All this reminds me of the famous quote from Jerry Maguire: "Show me the money!" Is there anything wrong with pandering to people's base desires, namely "If the government spends less money, we can lower my taxes without implications"?

skue 13y ago

> Another possible solution is to find a way to eliminate the for-profit hospitals. Oh God, no. Did you read that incredibly-long and incredibly-powerful healthcare article by Time? Non-profit hospitals are among the worst offenders. http://www.time.com/time/magazine/article/0,9171,2136864,00.html http://www.time.com/time/magazine/article/0,9171,2136864,00.... (subscription) Some of the most innovative hospitals are actually for-profit. Here's another great article by Atul Gawande comparing Steward Health System, which was founded by Cerberus Capital, to the Cheesecake Factory (but in a good way): http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_... > Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman. As an entrepreneur, I agree that it's a tragedy that HQP is being abandoned instead of scaled. But ACOs will absolutely have a financial incentive to keep patients out of the hospital and hire companies such as HQP. The problem is that this transition has yet to occur, so HQP is ahead of the market. Hopefully they can find smart investors in the meantime (perhaps this article will help).

ajtaylor 13y ago
I don't doubt that there are excellent for-profit hospitals. Chances are I've even used the services of one. One can find good things coming out of nearly every kind of business if you look hard enough. Please don't take the suggestion as anti-capitalist, because I'm not. My argument against them is simple: it's very hard to align the two goals of 1) making as much money as possible and 2) providing the best care possible, which in my mind means making their stay as short and inexpensive as possible. Even as a youngish person (late 30's), I don't want to go in the hospital at all and if I do have to go I want to be in and out as soon as it is safe to do so. The ultimate goal is to keep people as healthy as possible, and to spend the least amount of money to do so. This requires finding the right balancing point, but I'm positive it can be done if the political will exists.
- jacoblyles 13y ago
  > "I'm positive it can be done if the political will exists." In your lifetime, what major problem had the political will existed to solve it? As Moldbug says, we have a large government, but not a strong one.

roguecoder 13y ago

We already sort of had that in Massachusetts. For hospitals that treated large numbers of free care patients were given flat grants to cover operating costs. ("Free care" covers people too poor for health insurance or to pay for treatment and too young, childless, employed, healthy, etc. for Medicaid.) However, it is politically unfeasible, because people can't see what the money is being spent on and it was eventually eliminated to "save money". Even though local hospitals had created programs that helped lower costs and provided better care to populations normally ignored. People care more about punishing poor people than they do about saving taxpayer's money. Otherwise drug testing for medicare recipients wouldn't be a thing.