Tag Archives: medicine

We’ve dropped the ball on child health. Here’s why.

by Karan Chhabra

A superb essay by Dr. Matthew Davis in JAMA Pediatrics (gated) addresses one of the great shortcomings of modern medical research: despite the attention, money, and glamour associated with curing adult disease, pediatric diseases get nothing even close. Focused on the messaging behind pediatric research, he proposes that pediatric researchers take a new tack—that child health is, ultimately, adult health:

“Children are not small adults” is not working as a rallying cry. A recent comprehensive assessment concluded that “lack of research, poor research, and poorly reported research” greatly limit child health research… Contrary to intentions, “children are not small adults” has led research priority setters to disconnect the needs of children from the predominant national focus on the health and health care needs of adults.

Children are indeed different from adults—but that does not imply that children are not connected to adults. Rather, the exquisitely meaningful links between children and their caregiving family members, and between children and their later adult selves, are keys to converting current child health research challenges into opportunities.

Davis’s paper is provocative and worth a read. Beyond its scope, however, are the systemic causes and consequences of our underinvestment in child health. Messaging plays a role, but there is more to the story:

  1. Knowledge: Medical education reinforces the myth that kids are simply little adults. At most schools, the only substantive education students get in pediatrics is a required 6-8 week clerkship in their third year. But in years 1-2, when we learn most of the science behind clinical medicine, little to no time is spent explaining how kids’ biology is different. The implication, yet again, is that they work just like adults, which time and time again we find not to be true. Yet it’s not just students with this knowledge gap—the entire establishment seems to suffer from it, too. A lack of research on drug dosages and safety in kids means that the vast majority of drugs prescribed to kids in outpatient offices are prescribed off-label (without an explicit pediatric indication from the FDA). Legislation from 1997 has increased the amount of clinical trials involving kids, but even with that law, pediatric research’s share of NIH funding is still on the decline:
  2. pr2008226f2People: Yes, we’re low on doctors and nurses. But the workforce we do have is stilted away from what kids need, and it shouldn’t be surprising. Entering a pediatric subspecialty means additional training, which means more trouble paying debt, and likely less pay. As a result, pediatric subspecialists are missing in many geographic areas, have long wait times where they are present, and suffer high rates of burnout because of overwhelming demand for their services. The amount of pediatricians entering subspecialties is on the rise, but as with any discussion of the healthcare workforce, it’s all about location—are they entering areas where they’re needed?
  3. children and hospital resourcesIncentives: The root cause beneath much of this is probably that children just don’t get sickthat often. The chart at right illustrates how kids’ hospitalizations pale in comparison to adults’: despite making up almost a quarter of the population, they only use about 10-20% of hospitals’ resources—and when you cut out neonatal care, that drops to a measly 5% (more on that later). It’s certainly a good thing that kids are pretty healthy. But it creates a lack of incentive to develop resources specific to kids, from drugs, to care providers, to devices. I’ve mentioned drugs and providers here already, but the device story also deserves attention: because the market is smaller, companies have lagged in producing devices specific to kids. And many adult devices, like catheters and implants, simply don’t fit children. Recent policy will hopefully make it easier to research and approve new drugs and devices—but without modifying the underlying incentives, will they really close the gap?

Neonatology (intensive care of newborns, especially premature ones) is a well-known exception to most of the arguments I’ve been making–and with 7% of newborns admitted to a neonatal intensive care unit (NICU), the economics make sense. By way of comparison, only 2.7% of children aged 1-17 are hospitalized at all (let alone into intensive care). The promise of neonatal intensive care has improved dramatically—each decade the “limits of viability” allow one more week of prematurity—and with it, so have the economics. NICUs are known to be some of the most profitable components of pediatrics, so it shouldn’t be surprising that neonatology is one of the pediatric subspecialties least affected by shortage (though like the rest of medicine, it’s still maldistributed). There is one important exception to neonatology’s relatively privileged position: the unconscionable shortage of IV nutrition across the US. Since preemies need nutrition supplements more than any other age group, they’ve been most vulnerable to this crisis, and some have died as a result. The reasons for the shortage are complex, but most compelling to me is IV nutrition’s low profitability (since the mixtures are largely off-patent).

So what’s medicine to do?

The knowledge gap is probably one of the trickier problems to fix without taking resources away from other fields. Davis’s arguments on messaging will help with research, but they would do little to change the way doctors are taught. Individual schools modify the preclinical curriculum at their own risk: time not spent covering the topics in the USMLE Step 1 (the licensing exam required to enter years 3-4) is time that jeopardizes the future of those schools’ students—unless there’s a change in what Step 1 tests. Step 1 could change, if we had the will for it. Research funding is probably a similar zero-sum game: offering more funding to pediatric research usually comes with less funding for adult research. But extending patent protection for pediatric drugs, and making clinical trials easier to conduct—as current legislation does—seems to me a no-brainer.

“People policy” is moving in the right direction; Obamacare includes loan repayment programs for pediatric subspecialists who practice in underserved areas. But this policy has not been funded, which means it isn’t happening. We know that debt affects doctors’ practice choices, and that pediatric subspecialty fellowships are typically bad financial decisions—so these policies have a strong basis in evidence (if only they were implemented). Another way to spread the subspecialty workforce better would be to provide more attractive training opportunities where practitioners are needed most. Adult subspecialty fellowships are usually two years long, whereas those in pediatrics are three because they allow some time for research. Yet many say they’d prefer a two-year fellowship without research so that they could get into practice sooner (and presumably pay off those loans). Why not provide those opportunities, in the areas where those doctors are needed most?

Again, economics (specifically financial incentives) are at the heart of why we lack drugs for pediatric diseases. If we want to address this problem, we should address those incentives. A similar problem underlies the reality that we don’t have drugs for neglected diseases that affect the global poor—but many are calling for us to “delink” the development of those drugs from their profit margins. In short, delinkage boils down to the following (though you should really read Brian Till’s full article):

The use of cash prizes — rather than patents — to incentivize research; say, $2 billion for an effective therapeutic drug for Chagas disease. A cure, once developed, proven, and awarded a prize, would then exist as open-access intellectual property, with manufacturers around the world competing to produce the drug in the most cost effective manner. Implementing the idea… is effectively leveraging the power of the free market twice, once to produce the thing you want and then again to manufacture it as economically as possible.

The money’s already out there, in the form of research grants and the income streams that make it to the manufacturer of a successful drug. The idea of delinkage is to make those dollars flow toward where they’re needed most. If we want new agents for diseases in children, why wouldn’t this model wouldn’t work just as well?

As Davis notes, some of the most successful cures ever achieved—vaccines and sanitation—are essentially pediatric interventions that have improved the health of the entire population. It’s myopic to think there’s no more to be done.
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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Chargemaster Tomfoolery Part II: Are For-Profits Profiteering Off the Uninsured?

by Brian Clement and Karan Chhabra

A few weeks ago Karan used the recently released hospital charge data to ask how certain policies protect the uninsured–and where they might fail. (The short answer is: it’s complicated; they often backfire; an all-payer rate-setting system may help. But you should read his post.) He compared the average hospital charge “markup” in every state in the country, found that New Jersey’s were the most inflated, and then homed in on the most expensive hospital in New Jersey and the US (by charges to Medicare) [1].

The kicker? That hospital, Bayonne Medical Center, is a for-profit institution, and the only for-profit in NJ in the CMS dataset. Karan’s response: “I’m not suggesting this implies that all for-profit hospitals charge equally obnoxious rates, but someone with nice grants and research assistants should crunch the numbers for all 50 states and let us know.” Interestingly enough, a proposed federal regulation to protect the uninsured from excessive hospital charges applies only to not-for-profit hospitals [2].

So Brian Clement, a reader and friend of Karan’s, decided to explore the topic further. He also decided he didn’t need grants or research assistants, and ran the numbers himself. Here’s what he found.

  • For-profit hospitals have much higher markups than hospitals of any other ownership class (see below).

Charge Markup Percentage by Hospital Ownership

  • Why is that? Well, let’s break it down. The markup ratio has two components: the numerator is the amount charged to Medicare less the payment received from Medicare and the denominator is the payment received from Medicare [3]. As you might expect, we can see that for-profit hospitals are charging the highest amount to Medicare compared to hospitals in all other hospital ownership categories (see below).

Median Medicare Charges by Hospital Ownership Status

  • Despite charging more than any other type of hospital (as shown above), we can also see that for-profits actually end up getting the lowest payments from Medicare (see below)

Medicare Payment by Hospital Ownership

  • Important caveat, for the umpteenth time—the new data only reflect what Medicare pays out. They don’t show what private insurance companies, or Medicaid, pay hospitals. With that caveat in mind, isn’t this still weird? If for-profits know they’re getting lower reimbursement from Medicare than hospitals of other ownership statuses, why do they charge so much? Why do they bother charging Medicare so much if they’re not going to get nearly as much back? And why do we bloggers care if Medicare and insurers only actually pay a small fraction of those charges?

Well, we don’t know for sure, but we do know that they use their chargemasters to set charges for other payers, including uninsured patients. Unlike Medicare or insurance companies, the uninsured don’t have the bargaining power to bid down the charges in the chargemaster. So they’re more vulnerable to overcharging, and when they don’t have as much say in the hospitals they end up at (as in emergencies), they may really get exploited.

As Karan discussed in his last post, there are some policy approaches to protect the uninsured from these charges:

New Jersey has laws that protect the poor uninsured, requiring hospitals to bill them only 115% of Medicare rates [4]. The feds have actually proposed a similar regulation that would apply exclusively to not-for-profits—under this regulation, those hospitals could only bill patients qualified for financial assistance at the rate paid by Medicare or commercial insurance. The cutoffs for financial assistance vary at each hospital, but they tend to reflect some multiple of the federal poverty line. If this regulation is finalized, not-for-profit hospitals that violate it could lose their tax-exempt status—a threat hospital execs do not take lightly.

The federal reg won’t apply to for-profit hospitals, though. Since New Jersey’s doesn’t make the same distinction, I wonder why the federal law does… Yes, the federal policy uses tax exemption as a stick, whereas NJ is using hospital licensure, but the federal government has required other things of hospitals irrespective of tax exemption—why not use Medicare/Medicaid dollars instead, like EMTALA?)

With the new numbers in this post, an answer to this question is all the more urgent. In our admittedly amateurish legal analysis, it seems that the reason is that the federal regulation is written through the tax code and enforced by the IRS. Since for-profits don’t have any tax exemption to lose, there’s not much the IRS can do to penalize them.

But that’s under the authority allowed by the Affordable Care Act. Karan brought up EMTALA, the Emergency Medical Treatment and Active Labor Act, because it mandates all hospitals to stabilize any patient with an emergency regardless of their ability to pay—and regardless of that hospital’s for-profit/not-for-profit status. Instead of taxes, EMTALA’s enforced by participation in Medicare; if a hospital violates the law, it can’t receive Medicare dollars. EMTALA uses Medicare as a stick because it was written through the Social Security Act (which established Medicare); the federal proposal is written through section 501(r) of the tax code.

All that goes to say that more comprehensive federal protection for the uninsured doesn’t appear absolutely restricted to not-for-profits. If it were enough of a legislative priority, it could’ve been enacted through the Social Security Act and been enforced through Medicare participation rather than tax exemption. One could say that the ACA should make protecting the uninsured irrelevant, because it aims to make insurance affordable, but—thanks in part to the SCOTUS decision making Medicaid expansion optional—we still expect 30 million uninsured 8 years after the law’s full rollout. And the fact that the feds are issuing regs to protect the uninsured from not-for-profits shows that the uninsured are still on their radar. But if they’re going to try and protect the uninsured, they should make sure to protect them from the guys likely to fleece them the most.

Footnotes

1.  He defined “markup” as (average charge – average payment) / average payment. He calculated that for each DRG, for each hospital in NJ. So if a hospital billed $2000 and Medicare paid $1000, the markup was 100%. Then he averaged those markups in all the DRGs from each hospital to determine that Bayonne Medical Center overcharged more than any other state. For more on his methodology, see his original post.

2.  Under this regulation, those hospitals could only bill patients qualified for financial assistance at the rate paid by Medicare or commercial insurance. For the proposed federal regulation, see page 17 here. The cutoffs for financial assistance vary at each hospital, but they tend to reflect some multiple of the federal poverty line.

3. This dataset is for Medicare charges and payments only. We have no idea what they’re actually charging or receiving from uninsured patients based on that dataset, unfortunately. For Brian’s data and analysis, look here.

4.  Thanks to recent legislation, NJ limits the ability of hospitals to overcharge uninsured people under 500% of the federal poverty line—hospitals can only bill them 115% of what Medicare would’ve paid. But as Reinhardt notes, a family of four with gross income over $117,750 wouldn’t be protected. And more importantly, this isn’t true in every state.

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Brian is a Duke graduate currently working in healthcare consulting.

Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. Follow him on Twitter @KRChhabra or subscribe to the blog.

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Chargemaster Tomfoolery, Policy Responses, and Unintended Consequences (In Four Charts)

by Karan Chhabra

Nothing gets wonks going like a trove of healthcare data. On Wednesday, when the government released massive amounts of information on what hospitals charge Medicare, well, the wonks got going. Like many of them, I was skeptical of how much they mattered, since charge variations are a tired story. But a quick look at the numbers turned into a long adventure in healthcare economics, with lots of implications for state and national policy. What follows are the highlights of that adventure, without the computer crashes and med school things that fell in between.

CMS offers a useful summary by state, so I started there. The summary spreadsheet listed how much each state averaged in charges and payments for each of the most common DRGs (diagnosis-related groups). I noticed that my home state, New Jersey, seemed to be charging an awful lot. So I checked out how much hospitals charge relative to what Medicare actually ends up paying, which I’m calling “markup” [1]. Nationwide, median markup across all procedures was 216%. I ran some calculations to compare states and, sure enough, New Jersey was far above the rest [2].

average charges all states

Why? I was quick to suspect some Sopranos-style monkey business, but it appears to be—at least partly—an unintended consequence of a state law requiring insurers to cover out-of-network providers (h/t Dan Diamond). In-network hospitals confidentially negotiate rates for procedures with each insurer, which end up far below chargemaster rates. But under this law, out-of-network hospitals get payments that factor in chargemaster rates:

Patients who choose to go out-of-network will be billed based on the hospital charges, while insurers of patients who must receive emergency services at an out-of-network facility will also pay higher rates based on a “fee profile” that takes into account hospital charges … One reason for the high prices might be the state’s requirement that insurers pay for services at out-of-network providers. “It does create this perverse economic incentive for folks to charge more and more and more because they can get paid for it,” Sanders said.

In other words, NJ hospitals can inflate their chargemaster rates without any repercussions to the average insured patient (the state law will make sure their care is covered). So what we have here is a law designed to protect out-of-network patients from inflated charges, but with the apparent consequence of inflating chargemaster charges across the board. The Affordable Care Act includes similar protections for emergency room visits, enacted one year after NJ’s—will they have the same effect? The ACA provisions only apply to insurance plans written after September 2009, and CMS’s data are from 2011, so it may be too early to tell.

I still wondered if New Jersey’s charges appeared inflated because of one single hospital, or if it appeared true across the board. So to Jersey I went. I averaged the markups for every DRG in the dataset, by hospital, to see whether any hospitals systematically inflate charges across their entire chargemasters (blue columns in the graph below). Again, I broke out the markups for uncomplicated strokes (in red), just as an example. The results are in:

NJ charges by hospital

One hospital, Bayonne Medical Center, is orders of magnitude above the rest. For an uncomplicated stroke, they charge an average $101,394—but Medicare only pays them $5,667. The gap between charges and payments shouldn’t surprise anyone following healthcare delivery; Uwe Reinhardt explains it effectively and humorously here. But at this hospital, that gap is astronomical. (The median markup in NJ is 555% whereas the national median is 216%; since median calculations are insensitive to extreme values, Bayonne’s probably not solely responsible for NJ’s eminent position.)

The kicker here? Bayonne Medical Center is the only for-profit hospital in the chart. I’m not suggesting this implies that all for-profit hospitals charge equally obnoxious rates, but someone with nice grants and research assistants should crunch the numbers for all 50 states and let us know.

Here’s the funny thing: New Jersey has laws that protect the poor uninsured, requiring hospitals to bill them only 115% of Medicare rates [3]. The feds have actually proposed a similar regulation but one that would apply exclusively to not-for-profits—under this regulation, those hospitals could only bill patients qualified for financial assistance at the rate paid by Medicare or commercial insurance [4]. The cutoffs for financial assistance vary at each hospital, but they tend to reflect some multiple of the federal poverty line. If this regulation is finalized, not-for-profit hospitals that violate it could lose their tax-exempt status—a threat hospital execs do not take lightly.

The federal law doesn’t apply to for-profit hospitals, though. Since New Jersey’s doesn’t make the same distinction, I wonder why the federal law does—the feds aren’t trying to influence the charges for hospitals like Bayonne in any other state. Yes, the federal policy uses tax exemption as a stick, whereas NJ is using hospital licensure, but the federal government has required other things of hospitals irrespective of tax exemption—why not use Medicare/Medicaid dollars instead, like EMTALA?)

NJ’s law and the federal regulation matter to this debate because they protect the uninsured from chargemaster tomfoolery. Oddly enough, in a way they also disincentivize getting health insurance altogether. Since Medicare pays less than private insurance (115% of Medicare may also be a bargain), it could be cheaper to the patient to go uninsured under the protection of these laws, than to pay insurance’s overheads in the off chance that an emergency admission happens.

Insurance expansion is a crucial part of Obamacare. It also may be in jeopardy thanks to the IRS’s relatively toothless enforcement power for the individual mandate. At the end of the day, if you’re pretty healthy and of limited financial means, refusing to buy health insurance on the individual market is not the craziest financial decision you could make [5].

So what’s a policymaker to do? The two policies I’ve discussed—requiring out-of-network reimbursement, and limiting charges to the uninsured—both create perverse economic incentives. The first encourages chargemaster inflation, and the second undermines health insurance altogether. This is when cynics like me smugly invoke the law of unintended consequences. But there has to be a policy alternative that protects the poor and keeps the system sane, right? It turns out there is, but it’s a bit of a political grenade. So don’t say I didn’t warn you.

Look back at the first chart in this post. I talked about the biggest inflator, New Jersey, more than you probably wanted. What about that blip to the far right? Nope, no math error—Maryland’s markups are almost a hundredfold lower than NJ’s. It’s a story policy wonks know well: the state instituted an “all-payer” system for its hospital pricing in the 1970s, wherein every provider in the state is required to charge every payer the same price for the same service. This isn’t socialism–cash is still coming from the same places, and going to the same hospitals, and everyone is allowed to make money—but it is textbook rate-setting. The result? They’ve closed the gap between charges and payments, and slowed down cost growth in the process:

maryland cost growth

maryland charges versus costs

There are some flaws in Maryland’s system, but they can be remedied—Austin Frakt outlines them smartly here and here. First, it doesn’t make a ton of sense for each hospital to be paid the same amount when there are obvious differences in their amenities (and potentially their quality). It’s as if an upscale restarant were required to charge the same amount for a bacon cheeseburger as Burger King. Price controls by central dictat are also an ungodly administrative hassle. But it does make sense for each payer (insurance, Medicare, etc.) to pay the same amount to each hospital, the same way one restaurant patron shouldn’t pay less (at the same restaurant) because they’re bigger or better-insured. Thus Frakt, Uwe Reinhardt and others turn to Germany’s more market-based approach, where payers negotiate together for one rate for each procedure from each hospital.

This is a huge difference from the current system, where private insurers negotiate separately and confidentially, on the basis of concerns pretty irrelevant to patient care: most of all, market power. But it’s not “price controls,” because prices are reached through negotiation. Assuming we allow the uninsured to pay the same price, it essentially quashes the problem of price discrimination against uninsured patients, affords private payers the same power to bend the cost curve as Medicare, and makes plain sense—where else in the economy are different people forced to pay different prices for the exact same goods from the exact same seller? I haven’t fully come around to all-payer as the solution to all our woes, but 1500 words and four charts later, the proposal has definitely earned my interest.

 

Update #1, 5/17/13: The New York Times has just published a deeper dive into what’s going on at Bayonne Medical Center, specifically its use of out-of-network status to milk more from the system, and its switch to for-profit status. They have an accompanying editorial here. Go read, but tell ’em I sent you!

Update #2, 5/17/13: There’s an answer to my question in the last paragraph, “where else in the economy are different people forced to pay different prices for the exact same goods from the exact same seller?” It happens a lot when customers are bidding for goods that different people value differently (say, an auction). But the problem here is that with third-party payment, the patients are not the customers and bidders—insurers are. So the advantages of auction-style pricing—namely, pricing that accurately reflects the value of a product to each consumer—don’t apply in the hospital context. Instead, the system we have rewards market power at the expense of those who are most vulnerable. (Thanks to Austin Frakt for his insightful comments.)

 

Footnotes

1.  If you really want to know what I did in Excel, kudos for your bravery. I defined “markup” as (average charge – average payment) / average payment. I calculated that for each DRG, for each hospital in NJ. So if a hospital billed $2000 and Medicare paid $1000, the markup was 100%. Then I averaged those markups in all the DRGs from each hospital, to arrive at the percentages you see in the chart’s blue column. I broke out strokes in the red column just to make the data a little more concrete. You can access my spreadsheet here.

2. As I mentioned, I calculated the “markup” of every DRG in every state. Then averaged those markups within each state, and again broke out strokes as an example.

3.  Thanks to recent legislation, NJ limits the ability of hospitals to overcharge uninsured people under 500% of the federal poverty line—hospitals can only bill them 115% of what Medicare would’ve paid. But as Reinhardt notes, a family of four with gross income over $117,750 wouldn’t be protected. And more importantly, this isn’t true in every state.

4. For the proposed federal regulation, see page 17 here.

5. Not the craziest financial decision. But for the sake of your own health, as well as the ethics of living in society, it’s pretty dubious.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Paging All Millennials: How to Drive Healthcare Innovation

by Karan Chhabra

Dr. Kapil Parakh is a Johns Hopkins cardiologist and the cofounder of Health for America, a new program aiming to help young people make a difference through healthcare innovation. They run a summer program and yearlong fellowship for recent college graduates from a variety of backgrounds–though all interested in health–and are currently accepting applications (though the deadline is tomorrow!). Dr. Parakh joined us for this interview to tell us more about his organization’s unique model, and to get the word out about this opportunity.

KARAN: What motivated you to found Health for America?logo

DR. PARAKH: The main driving factor behind the vision for Health for America is to harness the power of young people to accelerate community-based innovation to battle chronic disease. According to the CDC, 133 million Americans are affected by chronic disease, accounting for more than 70% of all deaths. We know from reports by the Trust for America’s Health and the Commonwealth Fund that community-based programs targeting chronic disease could reduce disease burden and save lives while saving the system $306 billion over 10 years. Technological advances make this feasible, yet health innovation in the US remains focused on hospital-based care resulting in high costs and poor outcomes.

We have seen young leaders blaze pioneering paths in technology, and our systematic review found that they have limited opportunities to learn about innovation and entrepreneurship in domestic health field. Technology incubators like RockHealth are geared towards youth that have an idea and are looking to launch a company in months. Programs like Global Health Corps and Peace Corps are international; Health Leads offers limited volunteer opportunities while City Year and Code for America are not health focused. We designed a fresh approach that incorporates successful programs but avoids duplication.

Can you tell us about your experience designing a “startup” for heart failure patients within Johns Hopkins? How did that influence what you’re doing now at Health for America?

I am a cardiologist and the Director of Heart Failure at Johns Hopkins Bayview Medical Center. I led the creation of a program to improve the care of patients with heart failure—essentially a startup within a 240 year old institution.

Our program used Lean/Six Sigma to figure out the variance in care, we then used design thinking and brain storming techniques in partnership with IDEO to come up with solutions. Finally, we used Lean Startup to create MVPs and test these solutions. For example, we created new evidence-based order sets to help providers ensure their patients are on all the recommended therapies. We used an iterative process to come up with these order sets to meet the needs of interns and residents as well as hospitalists and cardiologists. Other interventions include the creation of an urgent clinic to address the needs of patients that were not doing well, revised patient education material and new support structures for our patients. The result was that our readmissions rates dropped substantially with better outcomes for our patients and cost savings for the hospital.

These experiences really highlighted the power of these approaches and helped shape the framework we developed at Health for America. The lessons learned helped guide our thinking in terms of the program structure and the role of fellows. We also see Health for America as a mechanism to show host institutions how they can use entrepreneurial approaches to innovate health care delivery.

What are the major differences between Health for America and a startup incubator (Y Combinator, Healthbox, etc.)?

That is a great question. Startup incubators are designed for people who have an idea, a team and need help and mentorship to launch a company. Health for America on the other hand is designed to give young leaders a deep dive into health entrepreneurship without requiring them to come in with their own idea and team. Our goal is to teach fellows the basic tools they need for health innovation and partner them with physicians, community leaders, and private sector organizations so they can experience the process of creating a health solution.

What have you and your team accomplished through Health for America up till now? What are you currently working on?

We are really amazed by the traction Health for America has gained since it was founded in 2012. We have had requests for collaboration from leading institutions from around the country. We were selected as one of 20 winners of the Case Foundation’s Finding Fearless competition out of nearly 1,200 nominations. My co-founder Madhura Bhat was selected as a 2013 SXSW Dewey Winburne Community Service Award recipient. We have been invited to numerous conferences to speak and have had hundreds of potential applicants reach out. We are now working on building upon this exciting start with the launch of our summer program with partners in Washington, DC and Lousiville, KY, which will focus on childhood asthma.

What would your ideal fellow or summer program participant look like? If a reader is interested in applying, how would you recommend they show their interest?

We are really looking for passionate changemakers from a variety of backgrounds including the fields of technology, computer science, art, design and health. You don’t have to be a pre-med or public health major and anyone with an interest in health is welcome to apply. We evaluate applications based on aptitude, creativity, integrity, teamwork and leadership and are hoping for a nice mix of applicants so that we can benefit from their diverse backgrounds and experiences. For more information, and to apply, I would encourage readers to visit our summer program’s webpage.

Karan is a first-year student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Today’s the Last Day to Make Sure Family Docs Learn about Contraception

by Karan Chhabra

I was pretty alarmed to read news today that training in contraception may be made optional for family medicine doctors-in-training:

The proposed new rules, they say, drop existing requirements that family medicine residents be required to undergo training in contraception and counseling women with unintended pregnancies.

Essentially, the board that oversees residency training (required for doctors to become board-certified) concluded that its educational standards needed more flexibility, and identified contraception education as one of those areas where it could lay off a little bit. Religiously-affiliated medical centers appear most likely to take advantage of this flexibility. But let’s be clear: this is a proposed change, not yet final, and it’s about training–not about whether reproductive health services can be provided. It’s also possible that trainees could learn a good deal about contraception through FOAM. So the sky isn’t falling, but I have serious misgivings about the precedent this sets.

A few months ago I offered my thoughts on the birth control debate as a whole:

The national conversation on birth control should look a lot more like ours on aspirin. When we talk about aspirin, we talk about about whether it’s right for you. When we talk about birth control, we get one-size-fits-all generalizations, political chaos, and name-calling. Something is wrong. These are individual, medical questions that demand individual, medical answers. Ethics have a place in medicine; faceless bickering and moralism do not.

I wrote those thoughts amid the debate on insurance coverage for contraception–a question that boils down to whether members of an employer-sponosred insurance plan ought to cross-subsidize people’s birth control expenses. In short, it’s thorny. Today’s question is different: should primary care doctors-in-training be required to learn how to provide services related to reproductive health? Should they be qualified to answer those individual, medical questions? To that, my answer is yes.

Family doctors are patients’ first line of trusted healthcare. In many parts of the country, they’re patients only line; not everyone can go to an ob/gyn for routine concerns like birth control. But we already have evidence that family doctors’ understanding of the research on birth control is inconsistent. Why make it worse? More importantly, though, what makes it okay to privilege certain types of medicine over others? Why is family planning any less a part of primary care than say, heart disease? If in fact it is, why can’t religiously-affiliated programs apply the same segregative logic to patients suffering from addiction or contemplating suicide, just because they disagree with it?

Medical education is about preparation. We go through medical school, residency, and all the rest to make sure that we can handle whatever our patients ask of us (within, of course, one’s specialty). Medical education should not be about judgment, about right or wrong, or about politics. It was one thing when the nation asked whether religiously-affiliated employers should pay for birth control. I believe it’s quite another thing when we ask whether our primary care doctors need to know about it. When authorities accept willful ignorance because of concerns that are at their core political, they attack the heart of a profession built on nonjudgmental service, and the patients who rely on it.

Today, April 25, is the last day for comment on this proposal. If you have something to say, do so in this form (courtesy of Reproductive Health Watch) and email it to familymedicine@acgme.org.

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Karan is a first-year student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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