October 27, 2018

The "secret sauce" of Kaiser Permanente

Financing and Payment Strategies to Support High-Quality
Care for People with Serious Illness: Proceedings of a
Workshop

A recent report by NASEM explains in one paragraph what is the key factor of succesful Kaiser Permanente model:
The “secret sauce” that enables Kaiser Permanente to deliver high quality care, explained Annet Arakelian, executive director of Medicare strategy and care delivery at Kaiser, is the way it has aligned its revenues and expenses. Kaiser’s revenue comes from the Kaiser Foundation health plan that collects premiums from groups, individual members, and some prospective contracts with government payers. Expenses go through a hospital
service agreement with Kaiser Foundation hospitals and a capitated medical service agreement with the Permanente Medical Groups that employ the physicians who work at Kaiser hospitals and clinics. The hospitals and foundation are nonprofit organizations, while the medical groups are for profit agencies with their own board of directors and governance processes. Incentives are aligned across the hospitals, health plan, and medical groups on quality metrics, as well as financial and regulatory initiatives.
Great definition. This is the ingredient for success. And you'll understand why it is so difficult to replicate in a private world with vested interests between different stakeholders: insurers and providers. The nonprofit element of the foundation and hospitals is crucial.

Second statement. Regarding the report on how to pay for serious illness:
Susan Wang, regional lead for shared decision making at the Southern
California Permanente Medical Group, explained that Kaiser’s approach to
comprehensive financing of serious illness care begins with a population
health perspective, which stems from the capitated arrangement that features
a fixed payment per person enrolled in its medical groups. “Because
we are capitated, we are accountable for our entire membership, it behooves
us to touch our patients at every opportunity,” said Wang
Summary: Kaiser has a patient centered strategy. Finance follows the patient not the specific illness. Great. Agree.




October 26, 2018

The media and the Theranos incredible deception

On Theranos failure, highly recommended for journalists.
From CBSNEWS, a basic piece to understand the power of the media in creating and destroying (false) value:

Was the media duped by Elizabeth Holmes?
A conversation with 60 Minutes about media coverage of the rise and fall of Elizabeth Holmes and her hot startup, Theranos

October 20, 2018

The biggest financial heist in history

BILLION DOLLAR WHALE
The Man Who Fooled Wall Street, Hollywood, and the World

In 2009, with the dust yet to settle on the financial crisis, a baby-faced, seemingly mild-mannered Wharton grad began setting in motion a fraud of unprecedented gall and magnitude – one that would come to symbolize the next great threat to the global financial system. His name is Jho Low, a man whose behavior was so preposterous he might seem made up.
An epic true-tale of hubris and greed from two Pulitzer-finalist Wall Street Journal reporters, Billion Dollar Whale reveals how a young social climber pulled off one of the biggest financial heists in history–right under the nose of the global financial industry–exposing the shocking secret nexus of elite wealth, banking, Hollywood, and politics
This book is specially helpful to understand our times. There are value creators and at the same time value extractors. Beyond them there is the greatest fraudster, Jho Low, a guy that stole $3.5 billion from Malaysian sovereign fund 1MDB, and helped former Malaysia president to get $700m.The total amount of the heist could be $6.5 billion, 2.5% of Malaysian GDP. If you want to know the details, just read the book.
It is strongly recommended to understand the corruption of the global financial system and audit firms  (Goldman Sachs, Deloitte et al.). This guy would not have been able to commit any theft without their help.
Once you have started the book it will be difficult to stop. Right now, there are others following Jho Low's path and value extractors are among us. Our institutions are extremely fragile tackling these issues. Just take this week cum/ex fraud:.
The German finance ministry said it was aware of 418 different cases of cum-ex tax fraud with a combined value of €5.7bn, adding that any guess about the total damage caused was “speculation” as the investigations were still ongoing.
An investigation published on Thursday by Correctiv, a German non-profit investigative journalism group, and 19 news organisations, cited leaked spreadsheets that show “an organised theft from the tax coffers of at least ten European states, besides Germany” that it claimed had cost taxpayers about €55.2bn.



October 18, 2018

Forecasting global life expectancy and morbidity

Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for 195 countries and territories

Key messages from The Lancet article:
Global life expectancy was projected to increase by 4·4 years (95% UI 2·2–6·4) for men and 4·4 years (2·1–6·4) for women by 2040, to 74·3 years (72·1–76·4) and 79·7 years (77·4–81·8), respectively.
Compared with the past, global progress in extending life expectancy was forecasted to be slower from 2016–40. This trend resulted from forecasts of slowed advances on key drivers such as SDI; worsening of several risks, particularly high BMI; and stagnated gains on cardiovascular diseases, which was a major factor in historical improvements in life expectancy.

October 11, 2018

Genome sequencing, what's it worth?

Evaluating the Outcomes Associated with Genomic Sequencing: A Roadmap for Future Research
The health economic evidence base for WES -whole exome sequencing- and WGS -whole genome sequencing- is very limited . A recent literature review identified just eight economic evaluations of either WGS or WES, six of which were cost-effectiveness analyses using diagnostic yield as the outcome measure. Only two publications presented cost-utility analyses using quality-adjusted life-years (QALYs) as the measure of health outcomes, as recommended by most health technology assessment (HTA) agencies. However, neither of these cost-utility analyses provides information on health outcomes that HTA agencies can use to inform the translation of NGS technologies into clinical practice for specific disorders.
Last May I wrote a post on this topic. Now James Buchanan and Sarah Wordsworth provide a roadmap for future research with three steps.
First, it is crucial that health economists generate evidence on the clinical utility of genomic sequencing using the methods and metrics that are recommended by HTA agencies. Here, we are primarily referring to the use of preference-based HRQoL instruments such as EQ-5D questionnaires to generate utility weights that can be used to calculate QALYs 
If there is reason to believe that patient wellbeing will change after undergoing genomic sequencing (for example, supportive qualitative evidence), but commonly used HRQoL instruments show no effect, a second step would be to explore the use of alternative health-state valuation techniques to generate utility weights within the QALY framework. The time-trade-off (TTO) technique is one such approach
A third step would be to make full use of existing evidence on the diagnostic yield of WGS and WES. Studies that link this evidence to patient survival and quality of life (for example, trials or observational studies with long-term follow-up), could inform decision making regarding the translation of these technologies into clinical practice.
Unfortunately, it is easier said than done. I'm dubious regarding the potential of QALYs on assessing value of such technology, despite I have no alternative solutions right now.


Exhibition at Saatchi gallery

October 6, 2018

Geisinger (it is not any fiord)

A suggestion for weekend reading: excellent interview by Eric Topol with the Geisinger Health System CEO, in Medscape.

Regarding genetics in clinical practice:
Our approach is based on asking, "What if we did whole-exome sequencing on our entire population?" We started this to see whether we could find medically actionable genetic conditions that we could do something about. We are 200,000 patients into it—or I should say, research subjects, because we started with research—and we have found that 3.5%-4% of those people have something actionable: BRCA, malignant hyperthermia, Lynch syndrome, genes associated with cardiac arrhythmia.
They are unique.

Banksy is a genius 

October 3, 2018

As time goes by

The order of time

I've just finished the book I started this summer: The order of time. It's quite difficult to enter in physicists territories, and time is the last frontier and a mystery. But Carlo Rovelli does a great job explaining in easy terms such complicated things.
This is the disconcerting conclusion that emerges from Boltzmann’s work: the difference between the past and the future refers only to our own blurred vision of the world. It’s a conclusion that leaves us flabbergasted: is it really possible that a perception so vivid, basic, existential—my perception of the passage of time—depends on the fact that I cannot apprehend the world in all of its minute detail? On a kind of distortion that’s produced by myopia? Is it true that, if I could see exactly and take into consideration the actual dance of millions of molecules, then the future would be “just like” the past? Is it possible that I have as much knowledge of the past—or ignorance of it—as I do of the future? Even allowing for the fact that our perceptions of the world are frequently wrong, can the world really be so profoundly different from our perception of it as this?
All this undermines the very basis of our usual way of understanding time. It provokes incredulity, just as much as the discovery of the movement of the Earth did. But just as with the movement of the Earth, the evidence is overwhelming: all the phenomena that characterize the flowing of time are reduced to a “particular” state in the world’s past, the “particularity” of which may be attributed to the blurring of our perspective.
 As The Guardian review says, the book is "an expression of the scientific desire to know and understand the world". Rovelli's message: time doesn't go by, time doesn't really exist as we imagine, it is only our construct.




La rumba del temps by Joan Miquel Oliver