Personal Responsibility

I had blood work done last week. I received the resulting report today. My triglycerides are high--much higher than the normal range. This puts me at increased risk for heart disease. I should alter my behavior to more healthy eating. Will I? I'm certainly going to try. However, I know how hard it is to stick to a healthy eating plan.

All of this got me to thinking about personal responsibility in the realm of health insurance. It is one thing if I don't know about a condition or risk factor, and get sick as a result. It is quite another thing if I am well aware of the risks of my behavior, but do not change my habits. Indeed, I believe if I am not able to change, I should be paying more of an insurance premium than someone that is willing to live a healthy lifestyle to decrease their risk of sickness. Why should others in my insurance risk pool subsidize my unhealthy lifestyle?

Now, all of this is quite a bit more complicated than what I present above. However, the general idea is clear. Those unwilling to change risky behavior, such as eating at McDonald's every other night, will be at higher risk of sickness, and should contribute more to their insurance pool. I know that this is currently done with smoking, i.e. non-smokers receive a discount on insurance. And, risky behavior is prevented in many life-insurance policies. But, to what extent to we take it? Insurance should be a way to financially protect myself against a catastrophic loss of income or wealth in the face of sickness. It shouldn't be a license for me to disregard my own responsibility for my health.

Here is a tricky follow-up question: What about non-behavioral risk factors, such as genetics? Should those with unhealthy genes be expected to pay more for insurance? Ouch. On the surface, that seems unethtical to me. It is something that I will need to think more deeply about.

"Moving knowledge from its source"

The Information Revoloution has resulted in a nearly infinite amount of information that can be accessed and applied to any particular problem. How is a medical provider supposed to sift through the endless streams of statistics, case studies, results, etc. and decide which information is most applicable to a particular patient's case?

According to Dr. Larry Weed, the current state of medical infrastructure leads to "knowledge being moved from its source." Dr. Weed is an innovator in the field of medical informatics, and has been advocating for knowledge/problem couplers for many years. Essentially, a coupler matches specific patient information with a vast store of medical literature to produce information that could assist in making diagnoses or rendering treatments. Dr. Weed's company, PKC, has been marketing its version of medical decision-support software (DSS) since 1982.

Unfortunately, a large number of medical providers are resistant to using DSS software. Some see it as an encroachment upon their judgement, while others simply do not trust the systems. However, as each new generation of medical providers is trained, these budding professionals will have been exposed to technology from a young age. Medical schools should promote the use of such systems.

It is impossible for any doctor to store all relevant knowledge in his brain. On top of the impossibility, it is unnecessary. Doctors should be trained in procedures for quickly finding relevant information instead of being encouraged to memorize as much information as they can possibly cram into their cranium (moving knowledge from its source.) Patients, too, should be given tools and encouraged to train themselves in matters of their health. Perhaps this type of training could be provided in health classes even at the high school and grade school levels. Using information in a responsible way could significantly reduce healthcare costs, both at the individual and macroeconomy levels.

THCB touched on this subject today, and I weighed in with a comment.

Big Pharma

The term "big pharma" seems to refer to the upper tier, for-profit pharmaceutical companies. Like many other "big" industries, such as "big tobacco" and "big oil", big pharma takes some criticism.

Last week, I ran across a post on Andrew Sullivan's blog, In Defense of Big Pharma. I clicked through the links to read the original article and most of the comments. I must say, the comments were nearly 100% pro-"big pharma", and I didn't even see anything in the original article that was overtly anti-"big pharma". Most of the criticism of the criticizers seemed to me much ado about nothing. However, it did get me to thinking about the pharmaceutical industry, and whether or not it exists in a fashion that best serves everyone. Obviously, competition is fierce, R&D is out of sight and it is a high-risk, high-reward enviornment for investors. Also, the industry has been extremely beneficial to the health of the country (note I'm not saying it has been optimally beneficial, but there is no doubt it has produced amazing drugs.)

No industry is going to be 100% completely free of crooks. So, there is inevitably going to be abuses in an industry and regulatory environment where conflicts of interest abound. However, I tend to the school of thought that believes the profit-motive is a good driver of innovation in the drug industry, and that the profits realized by these companies are a just reward for the large R&D outlays and risk. If these companies were not producing drugs that were valued by the health care community, they would not be able to survive long-term. Sure, their pharm reps may be able to wine and dine doctors into prescribing their version of Viagra, but long-term, if the product is unsafe or ineffective, eventually the truth would emerge, and the company would go out of business. That being said, I think that there should be safeguards in place to minimize the amount of abuse by those willing to "game the system" for their own advantage.

With the advancement of biotechnology, the question of drug development is destined to become more complicated. Eventually, drugs are going to be able to be produced to target very specific systems, conditions and gene pools. Taken to its extreme, a different drug could theoretically be produced for each individual human being that eliminated side effects and produced results. This may sound like science fiction, but the general direction is toward these types of drugs. How are large R&D costs to be recouped when the beneficiaries of drugs consist of a small pool of patients? What are the public policy implications? Should the small pool of patients bear the entire cost of the R&D for the drug that treats their specific and rare condition, or should it be spread among users of some of the more widely used drugs? Should it be spread among society in general?

Somebody, somewhere must bear the cost of drug development. This cost includes paying people for willing to assume the risk of financing the development of a failed drug. Although it is annoying to see so much money spent on advertising (money that could be channeled into more R&D or used to offset existing R&D and reduce prices), this is the by-product of a competitive environment, which in itself should help to drive down the prices of drugs to their end users. Overall, I think the current model does a pretty good job of organizing the inputs and factors of production (scientists, capital, testing methods, facilities, etc.) to produce a highly-valued product for society.

In rummaging through the comments from the post that ignited this reflection, I thought the following anonymous comment stood out as the most creative proposal for potentially changing the current system:

I'm sure there are many hooray stories and horror stories about "Big Pharma",
but they all presume there is no other way. Take a global view: Big Pharma has
the wrong business model.Three scenarios:1. I'm healthy, I need a pill to make
me feel better.2. I'm ill, I need a pill to cure me.3. I have a chronic
condition, I need a pill to keep me alive.All 3 pills come to market from a
business model where only 8 or 10 companies can afford to make that happen. It
takes around a Billion cash to get a drug approved, and the only way to recoup
that investment is to sell the pills at a commensurate price while patent
protection exists. Once generic comes in, the pill cost falls into the
competitive commodity market levels, much more affordable to the guy who needs
it.If you're in situation 1, and can't afford the pill, you pass. Situation 2,
you give up food for a while (you can't afford insurance, or insurance can't
afford to pay for the pill), Situation 3, government (read taxpayer) steps in or
you die.New business model: Have Pharma submit R&D proposals for development
(to the FDA?). Fund the good ideas, give a "home run" bonus to pills that make
the market. Government (read taxpayer) owns the patent, and pill production is
generic from the get-go. Risk/reward incentive for Big Pharma is there, pill
production is always commodity level pricing, and the sick guy can pay for the
pill in all three scenarios. Schedule D Medicare is not needed, everybody is
happy, even Big Pharma?

Revolution Health

Revolution Health

I just became aware of this Steve Case (co-founder of AOL) initiative. Other big-name players are on-board, such as former Secretary of State Colin Powell. I haven't yet delved into the details of the organization, but on its surface, it looks promising.

Update 12-21-06
Revolution CEO: John Pleasants

This morning, Fard Johnmar was invited to a beta-version of the website created by Revolution Health. Fard's post summarizes the challenges of the consumer-driven healthcare movement and how Revolution Health is trying to address such challenges.

Fard then goes on to give a brief tour of the beta-site and his opinions/analysis about whether or not the whole venture will work.

I'm sure we will all be hearing a lot more about Revolution Health in 2007.

Fard wonders if the company is trying to do too much. Personally, I think that there does need to be some major consolidation of medical information providers. Everyone wants to be the trusted site, but with so many sites around, none are all that well known, and it is hard to trust any of them. Perhaps Revolution Health can generate the type of trust for which I am looking.

Who's Who in Healthcare

Glasscock, Larry: The chairman, president and CEO of WellPoint Inc.
Iglehart, John K.: The founding editor of Health Affairs.
Stark, Pete:
Weed, Larry: Dr. Larry Weed is an advocate for increased use of medical information technology. He has made several contributions to the field of medical informatics through his company PKC Corporation.

Health Care Company Glossary

Amgen: Applied Molecular Genetics is the largest independent biotechnology company, and is international in scope. It had 2005 revenue of $12.5 billion.

Humana: Humana is a Fortune 500 Health Insurance company based in Louisville, KY. It has approximately 11 million U.S. customers, and $21.3 billion in revenue.

Institute for Healthcare Improvement: IHI is a not-for-profit organization based in Cambridge, MA with a vision of improving healthcare worldwide. The mission of the IHI is to both cultivate and help implement ideas for improving patient care.

Kaiser Permanente: KP is an integrated, managed care organization. It consists of a health plan (not-for-profit), hospitals (not-for-profit) and medical groups (for-profit). KP has 8.5 million health plan members. As of 2006, KP had $31.1 billion annual operating revenues.

Tenet: Tenet Healthcare Corporation is a for-profit, publicly traded hospital holding company headquartered in Dallas, TX. It is the second-largest hospital chain in the country.

WellPoint, Inc.: As of 2006, WellPoint, Inc. is the largest health insurer in the United States. WellPoint owns the BCBS brand in several states. The publicly traded company is headquartered in Indianapolis, IN, and had 2005 revenue of $45 billion.

Personal Health Records

I began using a personal health record yesterday. It is going to take me some time to compile my historical health care data, and in many cases I will have to make educated guesses. However, I'm looking forward to having a complete health history compiled in one location. Currently, my complete health history picture is fragmented across multiple providers, pharmacies and government agencies.

I read on THCB that Matthew Holt recently gave a PHR presentation at HIMSS. Matthew is relatively bullish on the potential of PHRs, but he thinks interoperability is going to be a major hurdle.

Glossary

Evidence-Based Medicine: EBM applies the scientific method to medical practice. According to the Centre for Evidence-Based Medicine, "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."

Personal Health Record (PHR): A Personal Health Record is created and maintained by the individual. A well constructed PHR will provide a complete and accurate summary of the health and medical history of an individual because it will gather information from many sources in a way that is not feasible in most health care settings.