Lab Soft News

U.S. Plasma Collection Centers Supply a Booming Industry But Is It Exploitative of Donors?

Earlier in my career I was a hospital blood banker and became familiar with commercial plasma centers that paid individuals for their plasma. Here's a link to the web page of one of them currently in business: CSL Plasma. Such centers are often located in poorer sections of towns. This aligns with the notion that they cater to people down on their luck who donate their plasma because of a financial need. The plasma collected in such centers has various uses including the manufacture of components such as albumin and coagulation factors. I had largely forgotten about this plasma industry until I read a recent article in the New York Times (see: What Is the Blood of a Poor Person Worth?).  Below is an excerpt from the NYT piece:

The plasma business is booming in the United States, with the number of collection centers ...more than doubling since 2005, and global sales roughly quadrupling since 2000 to be more than $21 billion in 2017. Many developed countries have banned paying people for their blood, but not the United States. Blood products made up 1.9 percent of all American exports in 2016, more than soybeans, more than computers....[T]here is an underside to all that growth: The industry depends on the blood of the very poor. Ethicists, sociologists, business executives and “plassers” themselves, as the donors are sometimes called, are increasingly asking: Is the business exploitative, taking advantage of desperate people? Or is it beneficial, offering much-needed income to those who have few avenues to make money? ....[P]lasma companies locate their collection centers disproportionately in destitute neighborhoods, according to...[a researcher on this topic] “They’re surgically placing these,” she said. Healthy people can donate plasma twice a week, up to 104 times a year. The plasma industry says that most people do not donate so frequently and that there are minimal health risks involved, but other researchers disagree. One 2010 study found that paid donors who sell their plasma frequently have fewer proteins in their blood, which some experts say could put them at risk for infections and liver and kidney disorders....

Here's another article on this same topic: Lift bans on paying for human-blood plasma. For me, the fascinating revelation in they NYT article was the size of the plasma business. Keep in mind the distinction between whole blood collection and plasma collection from the FDA perspective. The FDA requires that blood must be labeled as either "paid-for" or voluntary; Red Cross will not handle the commercial product. However, this F.D.A. labeling requirement does not apply to plasma because it is split into components before being administered to a patent (see: Why you get paid to donate plasma but not blood). Part of the huge global market for albumin is undoubtedly demand in China. Here are some more details about this aspect of the global demand for serum albumin (see: The big business of blood plasma):

China, a country that holds the questionable honour of being a world leader in liver disease, is now also the highest consumer of serum albumin, using 300 tonnes annually, roughly half of the worldwide total use....Serum albumin is most commonly derived from blood plasma, and over half of the albumin in China is imported. This increasing demand is driving up prices, and fake products billed as albumin have been found. Liver disease is a growing problem in China, primarily because of the high burden of viral hepatitis in Asia, but also because of the growing prevalence of non-alcoholic fatty liver disease.

Provider Organizations Beginning to Compete on the Basis of Value-Based Care

We are transitioning from a fee-for-service healthcare system to a value-based one. This new approach is not well understood, particularly by patients. Value-based care is characterized by the documentation of organizational efficiency and effectiveness combined with positive outcomes for patients. One of the major goals is cost-savings. This is in contrast to fee-for-service where providers decide which services are provided to patients with insufficient attention to outcomes. In line with these changes, some provider organizations are marketing themselves as value-based organizations. Details about this were provided in a recent article (see: Paladina Health acquires Activate Healthcare, creating large provider of value-based care) with a excerpt below:

Paladina Health, a direct primary care services company based in Denver, has acquired Indiana-based Activate Healthcare, a provider offering customized services to employers and unions for preventive and primary medical care. The collaboration creates one of the largest providers of value-based primary care across the U.S., serving more than 170,000 patients in 18 states....With a growing focus in the marketplace on alternative care delivery models that are patient-centric and value-based, Activate Healthcare has been cited as one of the faster-growing organization-based primary care providers...."This partnership underscores the need for innovation and change to improve the health and well-being of Americans while realizing medical cost savings for employers and unions within the healthcare delivery system," said Paladina Health CEO Chris Miller. 

This approach by Paladina Health and Activate Healthcare strikes me as ground-breaking. They describe themselves as value-based and promise better care combined with a low spend. Such an approach is obviously attractive to companies that contract out the primary care for their employees to these companies. Here are two quotes from the Activate Healthcare web site:

Aligned Incentives

We incentivize our physicians based on quality of care, rather than quantity of services delivered. Our physicians' accountability for the right metrics helps us deliver increased access and engagement for patients—this results in improved health outcomes and healthy, more efficient healthcare system use.

Data-Driven Approach

Our data-driven approach manages overall risk, including population health management, risk stratification and proactive outreach and communications. With this approach, we are able to address the specific health needs of your population—enabling us to drive health outcomes, lower cost and improve patient experiences.

Whether all of this is mere marketing hype will become apparent in time. However, I think that it's an important trend and other health systems may be headed in the same direction. The executives of these health systems will be turning to their quality leadership and IT departments to supply the data to document that they are delivering on the goals of improved outcomes, lower cost, and improved patients experience. Some of this data can be supplied by population health systems (see: Population Health Management: Systems and Success). The clinical diagnostic departments like pathology and radiology will also be key players in this data collection and documentation process.

PCP and Family Physician Wait Times increasing 50% in Many Markets

The majority of physicians in the U.S. are now salaried and working for large health systems (see: For the first time ever, less than half of physicians are independent). Also, wait times for an appointment with a family physician or primary care physician (PCP) are increasing (see: PCP wait times are 50% higher than 2014). This can be the source of great frustration for patients (see: Report: 20% of patients have changed doctors because of long wait times). These two facts may or may not be related. Here is an excerpt from the article on physician wait times:

The average patient waits 29.3 days to see a family medicine physician in large cities, according to a recent survey....This wait has increased 50 percent since 2014, according to the report....Of the 15 major metropolitan areas studied, average wait times for family medicine physicians exceed 14 days in 12 markets. Patients wait the longest to see a family medicine physician in Boston, clocking in 109 days on average. The shortest wait times are in Minneapolis, where patients wait an average of eight days to see a primary care physician, according to the report. Patient wait times have increased most for PCPs, though they are longest still for dermatologists. 

There are a number of possible reasons why appointment wait times are increasing for family physicians and PCPs nationally. For example, there may be fewer physicians functioning as PCPs (see: Can the dwindling numbers of primary care physicians explain decreased life expectancy?). PCPs may be spending an increased amount of time with each patient, attributable perhaps to the burden placed on them by the inefficiency of EHRs (see: 61% of Physicians Say EHR Systems Reduce Clinical Efficiency). Physician practices and appointments may not be managed optimally. Large health systems may be decreasing the number of PCPs in hospitals within a market because of the slim profit margins for their efforts (see: The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems; Actions by Amazon May Be a Preview of Expansion into Primary Healthcare). PCPs don't perform procedures (e.g., surgical procedures, colonoscopies) that are more generously remunerated than office visits by payers.

Obviously, long wait time to schedule a visit with a PCP can be frustrating for patients. However, does this necessarily mean that health problems are going unattended? I am sure that this is often the case but, increasingly, healthcare options are available other than physician office visits. One example is CVS/MinuteClinics which are growing rapidly (1,100 MinuteClinics inside CVS Pharmacy and Target stores). Walmart Care Clinics, of which there are about 2,000, is another example (see: 7 statistics on urgent care centers, EDs & retail clinics). There are also about 7,100 urgent care clinics in the U.S. (see: 7 statistics on urgent care centers, EDs & retail clinics). To restate the obvious, the long wait times to see a family practitioner or PCP may be driving patients toward urgent care clinics and walk-in clinics for which no appointment is required.

Cost of Hospital Care in Michigan; Numbers Not Necessary Relevant for Consumers

Hospitals are now being required to reveal their master price lists but these data may not be of much help to consumers (see: Hospitals must post prices online, but they may be more confusing than helpful). That's because the price lists displayed recently on the basis of a federal requirement, called chargemasters, are massive compendiums of the prices set by each hospital for every service or drug that a patient might encounter. However, I did find some of the prices published for a set of hospitals in Michigan by diagnosis were interesting in a general way to assess the cost of healthcare (see: Hospital price lists revealed: The cost of care at 9 Michigan medical centers). Below is an excerpt from this latter article:

....[W]hile a new federal mandate that took effect Jan. 1 requires hospitals to reveal their once-secret master price lists of every service or procedure they provide,...[but an expert of the topic] warned that patients should view the prices only as "context-setting" starting points. "The hospital's charges are not very relevant to the patient, because the patient bill can be significantly discounted, either by the health plan, which is what health plans have been doing for 50 years, or even in some situations where patients have to self-pay, they can negotiate by themselves"....Below, you'll find...[examples] of base and average prices for common hospital procedures provided by hospitals all over Michigan....:

Normal newborn birth:

• Metro Health, Grand Rapids: $1,835
• McLaren Bay Region, Bay City: $2,849
• Mercy Health Saint Mary's, Grand Rapids: $3,339
• Spectrum Health Butterworth, Grand Rapids: $4,088....

Concussions:

• McLaren Bay Region, Bay City: $10,646
• Covenant HealthCare, Saginaw: $13,473
• McLaren Flint: $15,840
• Spectrum Health Butterworth, Grand Rapids: $19,923....

Pneumonia:

• Spectrum Health Butterworth, Grand Rapids: $10,299
• Metro Health, Grand Rapids: $10,411
• Mercy Health Saint Mary's, Grand Rapids: $11,780
• Michigan Medicine, Ann Arbor: $12,796....

Femur fracture:

• McLaren Bay Region, Bay City: $14,206
• Spectrum Health Butterworth, Grand Rapids: $15,545
• Metro Health, Grand Rapids: $15,737
• Bronson Methodist Hospital, Kalamazoo: $16,539....

Just a reminder here for the uninsured. Many hospitals like the University of Michigan (Michigan Medicine) have financial assistance programs. Here's a quote from this institution about their program (see: Financial Assistance): A patient may receive 100% of their services free if their income is below 2½ times the Federal Poverty Guidelines and meets other financial criteria.

Should We Integrate "Longevity Medicine" into Mainstream Care

More than 12 years ago, I posted a blog note about the field of anti-aging medicine, longevity and its practitioners (see: Anti-Aging, Longevity Medicine, and Lab Testing) that included the following paragraph:

Just to frame the issue and get your attention, annual revenue from the anti-aging industry is estimated to be $56B  -- this includes products such as anti-aging cream and botox injections. Need to find an anti-aging physician?  No problem. Here is the link to the home page of the American Academy of Anti-Aging Medicine (A4M). It's not too late to attend the 14th Annual International Congress on Anti-Aging Medicine.

Since I posted this first note, there still seems to be a heavy dose of hucksterism in the anti-aging field. A patient visiting a practitioner often is screened with a large panel of lab tests to determine the difference between his or her chronologic and biologic age. Study of telomere length may be one facet of such testing (see: Easing the brakes on the "immortality" enzyme could slow aging). The consequence of testing is often to suggest the need for dietary supplements or anti-aging sera. Here's a typical web page located by a search with the term anti-aging (see: The Best Anti-Aging Secrets). Perhaps even worse for the patient may be the occasional advocacy of the physician for off-label administration of growth hormone as a kind of elixir of youth (see: Growth hormone therapy).

Perhaps the longevity and anti-aging "brands" are now so tarnished that they can't be rehabilitated. However, it did occur to me that it also may be the right time to blend longevity medicine with mainstream medicine. In my mind, preventive medicine overlaps with anti-aging medicine with the suitable goal of pursuing a longer and disease-free life for a patient. This can be accomplished by ameliorating the most common causes of premature death which are sometimes called lifestyle diseases (see: Seeking the Correct Definition for a "Lifestyle Disease"; Relevance of Lifestyle Analytics for Healthcare Organizations). This attention to "lifestyle" problems would involve attention to obesity, diabetes, daily exercise, smoking cessation, drug and alcohol addition/dependence, and adequate sleep habits.

Actions by Amazon May Be a Preview of Expansion into Primary Healthcare

I have posted previous notes considering the changes that are now occurring in the primary healthcare market including the efforts of CVS/MinuteClinic, Walgreens, and Walmart to gain market share (see, for example: Walmart Shapes Its Own Primary Care, Unbundling Strategy; The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems). This is in contrast to health systems that are not keeping pace because of the lower profit margins of such practices. Meanwhile, Amazon with its Prime business unit, seems to be positioning itself as a primary care provider. Some of these ideas were covered in a recent article (see: Amazon made another bold move into healthcare that went relatively unnoticed). Below is an excerpt from it:

Amazon expanded into the Medicaid market by announcing that it will offer beneficiaries a Prime membership of $5.99 a month, a discount of 54 percent. And while that revelation last week may not have raised quite as many eyebrows as the company's blockbuster partnership with Berkshire Hathaway and JPMorgan Chase it holds the potential to have a major impact sooner. "What Amazon is doing, they are trying to position themselves for a different market," ....They are disrupting healthcare at all levels. They're trying to be competitive with Walmart."....The Medicaid population isn't courted by providers because the lower reimbursement rates threaten their bottom lines. Insurers right now appear more interested in the Medicare Advantage market, though specialized government payers such as Centene are making the Medicaid segment work....

Amazon has been studying the healthcare market for at least a year...and began a competitive focus on Walmart last year with the start of Amazon Cash, which is a way to add money to an account to make quick ordering easier -- even for people who may not have a bank account, credit or debit cards. Taking that a step forward,...[a spokesperson] said she envisions Medicaid consumers talking to a physician via their smartphone for a $5, or even free, telehealth visit. "You can talk to a doctor with one click on Amazon Prime, who can tell you whether you need the emergency room," ...[an analyst said]. This helps keep beneficiaries from going to the emergency room for care, but may also cut into PCP services.....Amazon could also be considering a move into primary care.

To summarize, Prime has lowered its monthly membership for Medicaid subscribers and is now offering Amazon Cash membership to Prime members as a payment substitute for those lacking credit/debit cards or checking accounts. This will allow them to purchase items on Amazon and also, potentially, to take advantage of virtual care health (i.e., telemedicine) visits at low cost. Now that Amazon also controls retail store space in the form of Whole Foods stores, it could also potentially carve out drop-in clinic spaces like MinuteClinics in these stores. It will be fascinating to watch the next healthcare moves by Amazon (see: Amazon overtakes Google as the world's most valuable brand). The now huge company will surely pursue this line of business because healthcare is such a large proportion of the GDP and lower income and rural populations are not always well served by the current system. 

Major Trends for the Year: Payers Use IT to Provide Total Care Management

Approaching the end of years in the past, I have cited articles in Lab Soft News that summarize healthcare tech trends for that year. Here is a link to such a current article (see: 12 trends that will dominate healthcare IT in 2019) and below are the 12 trends cited as being relevant for 2018:

1. Using IT to help achieve patient engagement and experience
2. Rising efforts to achieve digital health
3. Accelerating the use of AI and data visualization
4. Rising importance of population health management
5. Growing efforts by payers to provide total care management
6. Pressing on toward interoperability
7. Pushing to achieve EHR optimization
8. Protecting health information and data security
9. The rising tide for value-based care
10. Growing the role for virtual care
11. The increasing influence of the cloud
12. Making wider use of clinical decision support and real-world evidence

One of the items on list that attracted my attention was #10, virtual care, about which I have blogged extensively. Here is one such example (see: Reducing Healthcare Costs with Virtual Visits; Tangible Evidence Provided). However, the most important item in the list, I think, was the reference to payers providing total care management (#5). Here are more details about this trend from the article:

Information technology will undergird payer efforts to migrate from pure claims administration and payment to burgeoning initiatives that help insurers offer care management and health optimization for those who they cover. Payers will embrace technology innovation more than ever before—companies like Bright Health, Devoted, Oscar and Clover are continuing to attract a lot of investment from the venture and private equity world because they’re seeking to offer a better user experience, and collect and utilize data in ways that will drive better outcomes—at lower costs.

This idea reminded me of recent blog notes in which I suggested that MinuteClinics were also using IT to improve the primary care experience and compete with health systems (see: CVS Offers Telemedicine Visits for MinuteClinic Patients; A Visit with a MinuteClinic Nurse Practitioner; My Observations and Conclusions). One of the companies in the above list, Clover, offers 24/7 access to doctors via phone, video call, or mobile app as part of its health insurance plan. This is thus an example of IT-enhanced services provided by a health insurance company.

A Visit with a MinuteClinic Nurse Practitioner; My Observations and Conclusions

I recently visited a local CVS MinuteClinic for a vaccination. I have previously blogged about MinuteClnics because I believe that they, along with the Walgreens and Walmart clinics, will attract a substantial share of primary care visits in the near future. Here are some of my previous notes about MinuteClinics (see: Details about CVS' MinuteClinic POCT Strategy; CVS Offers Telemedicine Visits for MinuteClinic Patients; The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems; Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care).

My first impression during the visit was that the nurse practitioner's office was relatively small, particularly when compared to the large CVS store in which it was embedded. This is not a criticism because the office was probably big enough for its purpose which is to see one patent at a time with a small waiting area outside the office door. What was different about this MinuteClinic practice, and perhaps differentiating it from that of some physicians, is that it is supported by relatively advanced IT that serves as a replacement for a receptionist and scheduler.

For example, one can make a MinuteClinic appointment on the web, afterwards receiving a code number which is entered into the computer outside of the office. Many of the patients seeking care in the clinic are walk-in's. Using the on-line appointment scheduler allows you to hold a place in line after inputting the code number that has been sent to you. There is a screen outside of the office announcing your approximate wait time. There is obviously a cost for the development and maintenance of these IT functions but computer system work 24-hours a day and don't take sick or vacation days.

Here's what I anticipate is going to happen with MinuteClinics and its walk-in competitors. Their existing "IT feature set" will expand because CVS + Aetna have the capital to invest in them. For example, patients may be asked to fill out a brief questionnaire and analytics will be used to help diagnose and care for the patient on arrival. Virtual care options will be grafted onto the current process so that incoming patients with more serious problems can be routed to the care of physician. EHR documentation of the visit will be automatic and generated with only a few key strokes. In short, these walk-in clinics will serve as development labs for a much higher degree of automation in primary care than is currently available. Contrariwise, I think that many health systems are reducing attention to their primary care options because the margins are slim for them.

Johns Hopkins Pediatric Hospital in Florida Suffers Soaring Surgical Mortality Rate

The prestigious Johns Hopkins Health System acquired All Children's Hospital in St. Petersburg, Florida, in 2011 (see: All Children's Hospital Joins Johns Hopkins Medicine). This was a non-cash transaction and the first U.S. hospital outside of the Baltimore/Washington, D.C., region to become integrated with JHM. As reported recently, this move has been the source of extreme embarrassment for Johns Hopkins as reported in a recent Tampa Bay Times article (see: Top All Children’s executives resign following Times report on heart surgeries). Below is an excerpt from it:

The CEO of Johns Hopkins All Children’s Hospital and two other hospital administrators have resigned following...an investigation that found dramatic increases in the hospital’s mortality rates for heart surgeries....In a statement, the health system said All Children’s CEO Dr. Jonathan Ellen, Vice President Jackie Crain and deputy director of the hospital’s Heart Institute Dr. Jeffrey Jacobs had resigned. Dr. Paul Colombani also stepped down as chair of the department of surgery....The...mortality rate at the hospital’s Heart Institute tripled between 2015 and 2017. Last year, it was the highest of any pediatric heart surgery program in Florida.....[T]he board of Johns Hopkins Medicine, which owns and operates All Children’s,...commissioned an external review of the issues within the heart program.....The...investigation reported that four physician assistants asked for a meeting with their supervisor and Colombani in 2015 to raise concerns about the surgeries performed by Jacobs and Dr. Tom Karl. At least four other employees also raised safety concerns....In June 2016, a third surgeon who had handled many of the most complex procedures was pushed out of the program.... Jacobs and Karl began performing all of the institute’s hardest surgeries. In the next 18 months, at least 11 children died after their procedures, even as the hospital began to turn away the most difficult cases....Kevin W. Sowers,..., president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, will step in and lead the hospital in a temporary capacity while a plan for interim leadership is put into place. 

One could say at this point that the Johns Hopkins strategy of acquiring a hospital outside of its home territory has been a major problem for the brand. The first idea that comes to my mind as an explanation of their problem is that "culture eats strategy," a phrase attributed to management guru Peter Drucker (see: Culture Eats Strategy For Breakfast. So What's For Lunch?). Here's a quote from this article:

...[B]oards appear to be paying only lip service to Drucker's tenet, according to a new survey by tax and accountancy firm Mazars....The study found that, despite culture being in the top three priorities for company boards, only 20% of 450 London-based directors and board members reported spending the time required to manage and improve it. Some 62% of survey respondents felt that they were primarily responsible for setting culture from the top of an organisation. However, a similar proportion (63%) either did not consider culture as part of their formal risk assessment or failed to routinely consider the risk associated with their corporate culture.

My guess is that the Johns Hopkins executives sitting in Baltimore assumed that their culture of hard work, high quality, and ethical behavior would be transmitted through the ether to their newly acquired pediatric hospital in St. Petersburg, Florida. They probably did not take the time and effort to manage and improve the local culture and are now paying the consequences for their actions in terms of a serious reputation hit. As noted above, "interim leadership" is being put into place but this will only be a temporary solution. A lot of building and damage control will be required.

Blurring of Definition of Big Medicine; Corporatization of Healthcare

Eight years ago I posted a note referring to an article in the New York Times (see: More Doctors Giving Up Private Practices) about the emergence of "Big Medicine" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"). In that note, Big Medicine was defined as being composed of the following organizations: (1) Big Pharma, (2) Big Payers (i.e., the U.S. government and large insurance companies); and (3) Big Providers (i.e., large consolidated regional health systems). A related concept now occurring in Big Medicine is its corporatization. As a result, physicians working in hospitals are now commonly referred to as providers and patients as customers. Here is a quote from a recent blog note that discusses the corporatization of medicine (see: Here’s what the corporatization of medicine is doing).

....[T]he “corporatization of medicine,”...[occurs when] the principles of depersonalized mass production — highly effective in retail business models — ...[are] imposed on health care systems, replacing the sacrosanct doctor-patient relationship with that of a commodity and consumer. Why is this happening? In the first three quarters of 2017, the top-five insurance companies made a record $6 billion in profit, with their executives getting handsome salaries and bonuses. The top CEOs of health care systems make seven- and eight-figure salaries. And their executives make equally large sums of money. When you receive that $25,000 ER bill, keep these exorbitant salaries in mind.

Another shift that is occurring in Big Medicine is that large retail drug companies such as CVS and Walgreens are becoming significant providers of the first tier of healthcare and Big Payers such as health insurance companies have become the employers of many thousands of physicians in competition with large health systems. In other words, there is a blurring of the originally conceived categories. I discussed this phenomenon in a recent blog note (see: OptumHealth, One of the Largest Employer of MDs, Pursues Telemedicine):

The largest employer of physicians in the country, OptumHealth is emphasizing virtual care. It is a division of the largest health insurance company in the country, UnitedHealth Group (see: Top 5 Largest Health Insurance Payers in the United States). UnitedHealth Group is also pursuing virtual care with its NowClinic subsidiary.....The third largest health insurance company in the country, Aetna, has now merged with CVS which is one of largest purveyors of walk-in primary care with its MinuteClinics (see: CVS Health and Aetna merger closes). These major health insurance companies may thus control at some point in the future a substantial portion of the first tier of healthcare as well as medical referrals associated with patients seen in their clinics.

Although I believe that value-based care needs to be substituted for fee-for-service with emphasis on outcomes of care, I believe that this goal may result in a lower quality of care in this depersonalized and increasingly corporatized healthcare environment.