Consumers & PatientsFuture of Health CareMedical Decision-MakingValue-Based Health Care
October 2, 2019

How Consumers Can Choose Quality in Value-Based Health Care

In our last article on how Quality should be reflected in Value-Based Health Care, we looked at the problematic route of quality measurement and reporting. The intent to develop payment for quality has resulted in a complex measurement system that produced provider-specific performance scores across hundreds of measures, yet has failed to advance achievement of better health care outcomes. The system creates flexibility for providers by allowing choice of measures, which eliminates consumers’ ability to see differences among providers. The quality agenda needs to mature. In its developmental period, there was a need to achieve consensus on the standard of…
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Future of Health CareMedical Decision-MakingResearch
September 11, 2019

Fixing Clinical Science Requires a Moonshot

“We chose to go to the moon” President John Kennedy’s statement instigated a monumental marshaling of resources to achieve a remarkable goal. Those famous words also established a powerful metaphor for aiming high. We need an equally monumental shift in purpose and commitment of resources for how we conduct clinical science. Nothing less than our nation’s health is at stake. In my view, there are only three possible ways research efforts might proceed: First, the conduct of research might not change, but continue to rely on observational studies and non-generalizable randomized trials (RTs). If so, populations of subjects included in…
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Future of Health CareMedical Decision-MakingResearch
August 21, 2019

AI May Be the Future, But It’s Not (Yet) the Future of Clinical Research

Good medical practice depends on good clinical research. Without rigorous, replicable, reliable research findings, we cannot trust that our medical decisions are based on truth. To put it bluntly, flawed research leads to bad medicine. It’s essential that we get it right. In this series, I have argued for a more rigorous approach. The present model of clinical research is expensive, slow, studies insufficient populations of subjects—making generalizability difficult— and lacks power to examine important variations in clinical and personal characteristics of individuals. In my biased view, study design determines if research is being done. Without an appropriate design, we…
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Future of Health CareMedical Decision-MakingPrimary Care PracticesValue-Based Health Care
June 26, 2019

Follow the Pathway to PCP Success In Medicare Direct Contracting

Primary care physicians were sitting on the sidelines as Medicare developed financial risk models in various generations of ACOs. At best, they could only hope to participate in Medicare Advantage and/or join a larger ACO. But potential for financial gain was elusive when the physicians’ success depended on the actions of others to achieve savings. Now Medicare is offering a carrot to large primary care practices with its new Direct Contracting (DC) models, luring them with the possibility of capturing higher and more predictable revenues as well as shared savings. CMS recently announced an initiative to test risk-based reimbursement models…
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Future of Health CareMedical Decision-MakingResearch
April 24, 2019

If Not Now, It’s Too Late: More Clinical Science Pitfalls and a Path to Improvement

Let’s review three major vulnerabilities with how randomized trials (RTs) are conducted, as discussed so far in this series. Critically appraising a research study involves determining the “internal and external” validity. Internal validity deals with the conduct of the study, per se. External validity deals with whether the study’s findings can be generalized to others in the population. Here’s what can go wrong: Populations being studied in RTs are too often convenience samples of patients/subjects rather than random or systematic samples of subjects. This diminishes our ability to externalize findings from the RT to the population at large. This is…
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Future of Health CareMedical Decision-MakingResearch
April 3, 2019

If Not Now, It’s Too Late: Simple Randomization Can Lead to False Inferences 
About Treatment Decisions

Medical decisions are best made on the basis of clinical science. Accurate research, shared between physician and patient, enables the patient to make an informed choice about risks and outcomes of treatment options. That’s how it should work, in theory. But in practice, even with the best shared medical decision-making, far too much clinical research employs faulty methodologies that limit the relevance of findings. This must change. In a recent blog post, I suggested that clinical science can improve by choosing more representative groups of people for study. Many clinical studies use convenience samples of patients rather than samples chosen…
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Future of Health CareMedical Decision-MakingPopulation HealthValue-Based Health CareWomen and Health Care
March 28, 2019

Women with Autoimmune Diseases Fight Uphill Battle on Every Health Care Front

Our articles on women’s health care issues have focused on areas that must change in order to provide better quality and outcomes, to lower costs, to advance treatment, and to treat women respectfully and equitably as patients and providers. We have demonstrated how women have been sidelined from getting the right health care because of two key systemic obstacles that must be addressed: Cultural bias that prevents accurate clinical assessment of symptoms and diagnosis, adoption or use of protocols relative to women’s biology, and effective health care therapies, and Inadequate basic science and clinical research that will illuminate sex-differentiated biology…
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Future of Health CareMedical Decision-MakingResearch
March 6, 2019

If Not Now, It’s Too Late: Clinical Science Is Futile If We Study the Wrong Population

In 1936, the Literary Digest, a respected national magazine, undertook a public opinion poll. Who would win the race between Republican Alfred Landon, governor of Kansas, and Democratic incumbent Franklin D. Roosevelt? Mock ballots were mailed to 10 million Americans. About 2.4 million responded—one of the largest survey samples ever created. Their prediction? Landon would carry the day. They were wrong—by a landslide for FDR. That’s because respondents were biased toward Landon and did not accurately represent the distribution of presidential preferences across all voters. Notably, George Gallop accurately predicted FDR’s victory using a smaller representative sample of about 50,000…
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Consumers & PatientsFuture of Health CareMedical Decision-MakingResearch
February 13, 2019

If Not Now, It’s Too Late: Clinical Science Needs Fixing

In 1967, the year I graduated from high school, my family’s television required “rabbit ear” antennae with perched aluminum foil. Our farming family had little time to watch TV, but when we did, the ritual included a side trip to reset the antennae’s angle to ensure good reception. Today, I watch a clear picture on myriad devices, no antennae needed. In the 1980s, my trips to a library to find medical literature were few. A single trip to the library would take hours and net only a small number of papers. Now, I obtain articles on any topic in a…
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Consumers & PatientsFuture of Health CareMedical Decision-MakingWomen and Health Care
January 30, 2019

Lessons in Health Care Empowerment from Women With Breast Cancer

For the one in eight women who will get breast cancer—more than 242,000 new cases were reported in 2015, alone, according to the CDC’s most recent data—the treatment is bad enough. Even more frightening is the uncertainty of what lies ahead. Will the cancer recur? And if so, when, and what’s next? Breast cancer kills 40,000 American women each year. Fear is a powerful motivator, because many women experience a recurrence of disease years after they were declared “cancer free.” Nonetheless, women with breast cancer have created an extraordinary movement that has changed how people see the disease and how…
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