Archivi delle etichette: Informazione in sanità straordinario mezzo per ricevere info automatiche @Medici_Manager

Scoperto! Un mezzo per costruire un’informazione quotidiana a partire dai tweet postati da 25 persone/istituzioni max.

Il mio quotidiano di chiama Leadership in Medicina: più valore e qualità cambiando il sistema e la cultura.

Per riceverlo nella vostra posta elettronica cliccate qui e poi +SUBSCRIBE.


Mobile Health 2012 @Medici_Manager

by Susannah FoxMaeve Duggan Nov 8, 2012


Fully 85% of U.S. adults own a cell phone. Of those, 53% own smartphones.

One in three cell phone owners (31%) have used their phone to look for health information. In a comparable, national survey conducted two years ago, 17% of cell phone owners had used their phones to look for health advice.

Smartphone owners lead this activity: 52% gather health information on their phones, compared with 6% of non-smartphone owners. Cell phone owners who are Latino, African American, between the ages of 18-49, or hold a college degree are also more likely to gather health information this way.


The results reported here come from a nationwide survey of 3,014 adults living in the United States. Telephone interviews were conducted by landline (1,808) and cell phone (1,206, including 624 without a landline phone). The survey was conducted by Princeton Survey Research Associates International. Interviews were done in English and Spanish by Princeton Data Source from August 7 to September 6, 2012. Statistical results are weighted to correct known demographic discrepancies. The margin of sampling error for the complete set of weighted data is ±2.4 percentage points.

The drug industry. Pick your pill out of a hat @Medici_Manager @doctorpreneur

Da The Economist

Bad Pharma. By Ben Goldacre. Fourth Estate; 430 pages; £13.99. To be published in America in January by Faber and Faber; $28. Buy from,

DOCTORS like to project an air of authority when making their clinical decisions. Patients like it too, for it is reassuring to think that one’s health is in the hands of an expert. It would be unsettling if, upon prescribing you a drug, your doctor admitted that the scientific research about what exactly the drug did, and how effective it was at doing it, was patchy and distorted, sometimes to the point where nobody has any real idea of what effects the drugs they are prescribing are likely to have on their patients.

But that is the reality described in “Bad Pharma”, Ben Goldacre’s new book. A British doctor and science writer, he made his name in 2008 with “Bad Science”, in which he filleted the credulous coverage given in the popular press to the claims of homeopaths, reiki therapists, Hopi ear-candlers and other purveyors of ceremonious placebos. Now he has taken aim at a much bigger and more important target: the $600-billion pharmaceutical industry that develops and produces the drugs prescribed by real doctors the world over.

The book is slightly technical, eminently readable, consistently shocking, occasionally hectoring and unapologetically polemical. “Medicine is broken,” it declares on its first page, and “the people you should have been able to trust to fix [its] problems have failed you.” Dr Goldacre describes the routine corruption of what is supposed to be an objective scientific process designed to assess whether new drugs work, whether they are better than drugs already on the market and whether their side effects are a price worth paying for any benefits they might convey. The result is that doctors, and the patients they treat, are hobbled by needless ignorance.

So, for instance, pharmaceutical companies bury clinical trials which show bad results for a drug and publish only those that show a benefit. The trials are often run on small numbers of unrepresentative patients, and the statistical analyses are massaged to give as rosy a picture as possible. Entire clinical trials are run not as trials at all, but as under-the-counter advertising campaigns designed to persuade doctors to prescribe a company’s drug.

The bad behaviour extends far beyond the industry itself. Drug regulators, who do get access to some of the hidden results, often guard them jealously, even from academic researchers, seeming to serve the interests of the firms whose products they are supposed to police. Medical journals frequently fail to perform basic checks on the papers they print, so all sorts of sharp practice goes uncorrected. Many published studies are not written by the academics whose names they bear, but by commercial ghostwriters paid by drug firms. Doctors are bombarded with advertising encouraging them to prescribe certain drugs.

The danger with a book like this is that it ends up lost in abstract discussion of difficult subjects. But Dr Goldacre illustrates his points with a plethora of real-world stories and examples. Some seem almost too breathtaking to be true—but every claim is referenced and backed up by links to research and primary documents. In scenes that could have come straight from a spy farce, the French journal Prescrire applied to Europe’s drug regulator for information on the diet drug rimonabant. The regulator sent back 68 pages in which virtually every sentence was blacked out.

And of course, the upshot of all this is anything but abstract: doctors are left ignorant about the drugs they are prescribing, and which will make their patients sick or get well, or even live or die. Statins, for instance, lower the risk of heart attacks, and are prescribed to millions of adults all over the world. But there are several different sorts of statin. Because there is little commercial advantage to be gained by comparing the efficacy of the different varieties, no studies have done so in a useful way.

Bereft of guidance, doctors must therefore prescribe specific statins on the basis of little more than hunches or personal prejudice. As Dr Goldacre points out, if one drug is even a shade more effective than its competitors, then thousands of people prescribed the inferior ones are dying needlessly every year for want of a bit of simple research. That is a scandal. Worse, the bias and distortions that brought it about are repeated across the entire medical industry. This is a book that deserves to be widely read, because anyone who does read it cannot help feeling both uncomfortable and angry.

Where the Candidates Stand on Medicare and Medicaid @ProPublica @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by Suevon Lee ProPublica, Sept. 14, 2012

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues of the campaign.

With the candidates slinging charges, we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:


Big Picture

Earlier this year, the Medicare Board of Trustees estimated that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says is on an “unsustainable path.” On hiscampaign website, Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep for now.

Romney has proposed raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he wouldindex eligibility levels to “longevity.” Ryan’s budget plan proposesraising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposedraising the age of eligibility.

The Congressional Budget Office estimates that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percentBut it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized such spending cuts in his speech at the Republican National Convention, his own budget proposed keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restorethe $716 billion savings that the health care law imposes. Per this New York Timesstory, the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation.

Caps on Spending

Both Obama and Ryan have set an identical target rate that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Boardthat, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo, Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated clear proposals for imposing a cap on spending.


Big Picture

Though, it’s far less discussed on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans.  The Affordable Care Act has expanded Medicaid coverage further. Beginning 2014, Medicaid will include people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled that states could opt out of the Medicaid expansion. A ProPublica analysis estimated that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion over the next nine years.

Actual Impact                                                                                                     

The New York Times points out that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.

Hospital Rankings Get Serious @ashishkjha @Atul_Gawande @drsilenzi

Le “classifiche” degli ospedali diventano una cosa seria. Straordinario post  di Ashish Jha sul suo blog “An Ounce of Evidence”. Medico, ricercatore di politica sanitaria, Ashish Jha sostiene il concetto che un’oncia di dati vale molto di più di migliaia di libbre di opinioni.

Il post riporta i dati sulle “classifiche” degli ospedali da parte di tre organizzazioni: The Leapfrog Group; Consumer Reports; US News & World Report.

Metodologie diverse, risultati diversi!

Analisi molto approfondita e commenti immediati da parte di Consumer reports e The Leapfrog Group.

Anche in Italia il programma nazionale esiti di AGENAS  e la partecipazione di alcune Aziende Ospedaliero-Universitarie ( al momento Udine e Verona ) a Global Comparator di Dr Foster va nella giusta direzione.

Doctors: Find balance between work and social media @drsilenzi @kevinmd


In a previous post on the Social Media Healthcare blog, I made an argument as to why physicians should be involved in social media—especially on Twitter.  The purpose of this post is to describe how I use social media as a busy clinician and teacher of family medicine to keep up to date with clinical and policy information and  also how I find the time to use social media. Yes,  social media can fit into a busy schedule.

One of the most daunting challenges facing any newcomer to social media is the volume and scope of information that is available.  Once one starts following other social media accounts, the incoming “stream” of information can quickly become overwhelming. A number of social media participants have likened it to drinking from a firehose.

In many cases, these streams of information are also not uniformly useful: friends’ updates may be personally important, but can make it harder to find relevant clinical or policy information.  It can also become quickly apparent that trying to keep up with every update on Twitter or Facebook is an exercise in futility and will take up the better part of your life.

Here are some tips that I have found useful:

  • Stop trying to read every update.  Early on, when I was new on Twitter, I would try to read every single update posted and visible in my timeline.  This took a ridiculous amount of time.  Instead, I have come to understand that I cannot read every update.  Instead, when I log into my accounts, I’ll glance at what updates are there and look back a bit at previous updates.  I trust that anything that is really important will be shared or commented upon more than once, and I have come to appreciate the randomness and serendipity associated with dipping my toe in the stream every now and then.
  • Organize your incoming information: this is one of the most valuable tricks that I have found.  Instead of trying to search my overall Twitter feed (I follow nearly 1,500) accounts, I have created lists that allow me to focus on certain themes.  I have a list for updates regarding health policy,clinical updatesfamily medicine-specific accountspeople in Richmond, etc.  Perhaps the most useful is the list I’ve titled “essentials”: this list includes accounts that have an especially high value for me whether it is because of the quality of material they share, the topics in which they are interested, etc.  When I have only a short window of time, I can skim the essentials list and get high quality information in short order.  Given that I use social media as myself and as administrator for a few organizational accounts, this list lets me find information I can share from various accounts.
  • Use time wisely. Each social media user has different times of day when they might review their accounts: over breakfast, at lunch, etc.  However, you can make use of “interstitial time” (credit toPaul Tatum).  If you have a computer or mobile device available, you can glance at your stream during the time that you’re waiting for the nurses to room a patient, or if a patient no-shows.  These short windows of time can add up.
  • Look into using a third-party Twitter client, such as TweetDeck or HootSuite.   Twitter clients allow you to better organize the incoming information, and let you see multiple lists simultaneously.  If you are sharing information, Twitter clients also allow you to share on different platforms (Twitter, Facebook) and via different accounts.  This is a tremendous time-saver.  I am not beholden to any particular client: I use TweetDeck on my laptop, HootSuite on my mobile devices, as it seems to be a better fit for them.
  • Leverage your e-mail newsletters.  If you subscribe to any e-mail newsletters, you can use them to find resources that you can then share to your account’s followers.  For example, the American Academy of Pediatrics Smart Brief includes short capsules of useful information.  You can read the capsules, click to read the full article, and then share that directly to your social media accounts.  This prevents you from duplicating work, and allows others to see information you found to be relevant.  You can do the same with Physicians First Watch, and numerous other sources.
  • Finally, if you do not have much time to be on social media, look for relevant Tweetchats.  These live online conversations are identified by a “hashtag” (i.e. #hcsm stands for healthcare communications and social media; #MedEd represents medical education, etc.—find a full listing here), scheduled at a pre-set time and day, and bring together a number of individuals and organizations with shared interests.  This can be an efficient way to make new connections, and to share information that can benefit the community of users.

In summary, do not be afraid that being on social media will inundate you with useless information and eat up any and all free time.  There are ways to compress and increase the efficiency of your social media use to ensure that you find what you want to find, share what you think is relevant, and make meaningful connections with other users.

How do you find balance between work and social media?

Mark Ryan is a family physician who blogs at Life in Underserved Medicine and The Doctor’s Tablet, where this post originally appeared.

Take the time to educate yourself before forming an opinion @kevinmd @drsilenzi @agnescheer

by  | in PHYSICIAN

Student loan debt is at an all-time high at a little over 1 trillion dollars, a figure that now, for the first time ever, exceeds our nation’s credit card debt. Higher education has never cost more, the rate of rise of college tuition having exceeded in recent years the rate of rise of many other services. Perhaps as a result of this, as well as of the difficulty in obtaining a job after college in today’s market, more people are questioning the value of a college education than ever before.

Not that anyone is questioning the value of an education itself (at least, not more than they ever did). The value of education is so firmly established that I won’t bother debating it here. But we do seem to be in the midst of an education crisis, and not just because higher education has become so expensive.  Wikipedia lists the rate of functional illiteracy in the U.S. (as measured between 1994-2003), for example, at 20 percent.

There are a number of reasons this statistic fills me with dread, but I’ll mention only the one I find most troubling. The solutions our political leaders seek for our most pressing problems are largely determined by which are most popular. And which are most popular is largely determined by our population’s ability to understand the problems for which the solutions are being proposed. Which, as far as I can tell, is dismal. Which means the most popular solutions are also the solutions most likely to be wrong. Which means our population’s lack of education is compromising our political leaders’ ability to solve problems. (If enough constituents understood, for example, the true causes of our current economic crisis and demanded real fixes instead of the appearance of real fixes, politicians might actually feel able to implement them without committing political suicide.)

What else might explain the popular notion that we don’t want a President who’s “too intellectual” other than a poorly educated populace that finds itself unable to identify with such a characteristic? Certainly, intellectualism could be considered antagonistic to decisiveness, but what’s been implied here is that we aren’t best served by having the smartest, most educated person in the office.

We all seem too quickly satisfied with the easy answers our politicians spoon feed us. Perhaps it’s because we’re all too busy to thoroughly investigate the causes of our country’s problems ourselves. Perhaps it’s because we feel powerless to do anything about them. But if we don’t educate ourselves, if we allow our politicians and pundits to do our thinking for us, we won’t be able to demand of our leaders effective solutions for our problems.

For the real solutions to our problems aren’t easy to understand. How do you fix healthcare? First by understanding what’s wrong with it. But how many of us really understand that? We know how its flaws affect us:  long waits to see doctors, high insurance premiums, and the risk being bankrupted by a serious illness. But we don’t understand the root causes of those effects. So we can’t really understand what fixes will work. The health care law is over 1,500 pages long. How can anyone know if they don’t like it if they don’t know what it says? The media has held up certain parts of it for public inspection, but without first understanding the root causes of the problems it’s trying to solve, how can anyone possibly judge the quality of its solutions?

I’m not arguing for or against the health care law here. I’m arguing for taking the time to educate ourselves thoroughly before forming an opinion—for the general population to elevate its level of education in general (note I’m not addressing how: that’s an entirely separate topic). Because our collective opinion has power. If our political leaders seem to be pushing our country toward a cliff, it’s only because we the people are pushing them to do it.

Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World.

Healthcare 2020 – Bain & Company @drsilenzi @agnescheer @muirgray

By George Eliades, Michael Retterath, Norbert Hueltenschmidt and Karan Singh

We have been talking about healthcare costs for more than 40 years, but the worldwide financial crisis and subsequent climate of austerity are finally catalyzing change. Payers are searching for all available tools to stunt the growth of a sector that has successfully resisted cost containment for decades. Adding to the urgency for action is an anticipated global surge in demand precipitated by several factors: an aging population with chronic care needs, population and income growth in emerging markets and the potential for insurance coverage expansion due to health reform in the US and around the globe.

An increase in demand—even one accompanied by cost pressures—is generally good for companies supplying products to the healthcare sector. But in this case, it is concomitant with a precipitous decline in research and development productivity for pharmaceutical and medical technology companies, leading to a more than $100 billion loss in product exclusivity by 2015.1 Despite ongoing medical need across many diseases, these players can no longer depend on their innovation engine and pricing power to drive ongoing profit growth. The net result will be an unprecedented decline in the share of the overall healthcare profit pool captured by innovation-driven companies in favor of lower-margin sectors like generic manufacturers and providers.2

We do not suggest that healthcare will be less innovative over the coming decade, but rather that the focus of innovation will shift from the product arena to healthcare delivery. A demand surge in an environment of fiscal constraint and slower product innovation will create a climate that favors investment in new ways of delivering care, in part by applying the power of information technology—long overdue in healthcare, relative to other sectors. Indeed, the shift in emphasis from managing inputs, like the rate of adoption of new products and the number of physician visits, toward delivering outputs, like patient satisfaction, clinical outcomes and overall system savings, is already well underway.

Going forward, the critical question for companies will be how they can evolve their business model and thrive in a world of shifting profit pools by focusing on delivering better outputs, rather than by simply generating more inputs—more products, more procedures and ultimately more cost to the payers.

All of these disruptive changes will have two significant implications for the global healthcare market:

  • There will be radical changes in the relative size and growth of the various parts of the global healthcare profit pool. In the past, growth by sector has been relatively consistent, but by 2020 and beyond, growth rates across sectors and geographies will diverge.
  • The basis of competition in the marketplace will change as well. Different therapeutic areas will be affected in distinct ways by two significant trends: growing consumer engagement and increasing standardization of care (“protocolization”).3

How will you compete as global profit pools shift?

Even though the global profit pool will expand over the next 10 years, most players will need to develop new business models to win. We believe the total profit pool will grow at a compound adjusted growth rate (CAGR) of 4%—from $520 billion in 2010 to $740 billion in 2020—but lag overall healthcare expenditure as profitability declines in aggregate worldwide4 (see Figure 1).

Your business plans for the next decade will require a deeper understanding of the sector and regional shifts embedded in these global figures. For example, most of the growth in the global profit pool will come from increased volume in the delivery of care, while another significant source of growth will come from smaller sectors like contract research or manufacturing and nutrition, which are experiencing significant growth from a smaller base, particularly in the emerging markets.

Pharmaceutical companies will see low growth and some decline in margins over the coming decade. Brand-name pharmaceuticals will grow only 1%, and the market will become increasingly fragmented, as the main source of revenue growth will be smaller items like targeted oncology products.5 In the US the situation will be even worse, as the forecasted 1% growth rate will depend on substantial growth in the second half of the decade, overcoming patent expirations and pricing pressures. At the same time, generics will grow by 7%, driven by those same patent expirations as well as increased volume in emerging markets (and a few underpenetrated developed markets).

healthcare-2020-fig-01A_embedClick to enlarge

healthcare-2020-fig-01B_embedClick to enlargeGlobal medical technology products will grow 3%, but with lower profit margins due primarily to worldwide pricing pressure. The slowdown will come mainly from peak penetration of products, such as stents, in developed markets and competition everywhere from “good enough” products. In China there is already fierce competition from locally produced stents, and this pricing pressure will continue as the Chinese and others develop cheaper alternatives.6

New healthcare value chain players will expand the overall profit pool to some degree. While margins in almost every other sector will slow, the growth in these sectors will be dramatic. Contract research, manufacturing and sales companies and healthcare IT companies will see significant volume growth as pharmaceutical companies outsource more functions and the demand for data accelerates.7 Contract research organizations will expand through greater use of strategic alliances and risk-sharing arrangements with pharmaceutical companies. Contract manufacturing organizations will see 8% CAGR, in part due to their expansion into China and India.

Because of the uncertainty of health reform in the US, payers are not likely to experience the growth they have experienced in the past. Even if there is more insurance coverage, there will be lower margins because of pressure on premiums. In fact, the traditional business model of US health insurers is increasingly coming into question with the rise of accountable care organizations (ACOs). The net result is that the expansion in worldwide insurance coverage will come largely from emerging markets, with growth in Europe remaining fairly stagnant.

Providers of care worldwide will see the largest volume gains, but not necessarily any increase in their overall margins. These volume increases will drive 30% of the overall profit pool growth (about $70 billion), but profitability will be flat or will decline. In fact, the overall profitability of healthcare players is expected to decrease by about 1% by 2020.8 The slower growth in US and European markets will be offset to some degree by expansion in emerging markets like China and India, specifically for generic drug products. Rapid economic growth and the rise of chronic diseases will produce substantial gains for price-sensitive generic products, but weak medical insurance and gaps in delivery capability in rural areas will remain challenges for these economies.

China’s healthcare profit pool will grow from about $22 billion in 2010 to $113 billion in 2020, a CAGR of 18%, 9 suggesting appealing opportunities for new investments, but hospitals and other providers will drive 40% of that growth (see Figure 2).10 Those providers will benefit from an aging population and a rising middle class, and there are also some signs of government policies that are favorable to private investment in the sector. Pharmaceutical and medical technology companies will continue to realize attractive earnings before interest and tax (EBIT), but brand, generic and over-the-counter products will shrink by one percentage point because of government-enforced price cuts and the increasing purchasing power of distributors.

Likewise, in India, the delivery of care and pharmaceutical sales will make up most of the fragmented $65 billion market.11

healthcare-2020-fig-02_embedClick to enlarge
Disruptive changes will alter the basis of competition, creating new opportunities to redefine business models and enter new markets

The sheer size of emerging markets makes them attractive offsets to more stagnant growth in other regions of the world. But to be successful, companies will need new business models to take advantage of the opportunities there (see Figure 3). Profit pool shifts and the lack of access to healthcare in many countries, for example, may spur some pharmaceutical and medical technology companies to meet the challenge by opening clinics in the developing world, or even entering the private insurance market.

In the developed world, providers and payers are already entering the device or drug market. Companies like Fresenius Medical Care, which started out producing dialysis machines, have emerged to “own” an entire segment of care—vertically integrated with machines, clinics and drugs. With global government spending estimated at about $50 billion for dialysis products and services, but with shrinking reimbursement per treatment, the vertically integrated model may be an effective path to capture a very specific part of the profit pool.12

healthcare-2020-fig-03_embedClick to enlarge
While the specificities differ by market, the overall trend is that companies are seeking incremental growth in new profit pools that tie to disease knowledge or market know-how.

On what basis will you compete? If you can no longer depend only on increased volume or control pricing, where can you most profitably operate in the newly configured global market? This is where the acceleration of twin trends—consumer-driven demand and standardized and protocolized care—comes into play. These two trends are powerful and have the capacity to facilitate the shift to outputs over inputs, stimulating new opportunities for profitable growth, if you can adapt your business model.

  • With more information about treatments available to an increasing number of consumers or patients around the globe, every company with a product to sell must understand how best to engage with consumers, in a way that speaks to their individual needs and patient experience. Search engines have produced a vast engaged patient population we could not have imagined even 10 years ago: 80% of Internet users now search for health information online, and more than half look for specific information about a medical treatment or disease.13 The demand for more engagement is not limited only to the US and Europe. Mobile phones and Internet access are now available in most emerging economies. While there will continue to be cultural differences in the way consumers engage with their care, the degree of engagement itself will only intensify globally. More than one-third of Indians, for example, currently use the Internet to search for health information, with similar percentages of younger, more educated people seeking health information online in Brazil, Mexico and China.14
  • Along with the trend toward increased consumer engagement is an increasing professionalization of medical care processes. We call this trend protocolization because physicians and other providers are accepting and using more standardized protocols and guidelines for treating their patients. US providers have been somewhat slower to embrace clinical protocols than their European or Asian counterparts, but there is little doubt about the direction of this change. No longer will the individual physician be the lone decision maker. The cottage industry of medical care is being industrialized, as payers and providers increasingly align their businesses—and results—which may be threatening to some, but may well produce better care at lower cost.

Protocolization and consumerism will not affect all therapeutic areas equally

There are at least four “landscapes” where healthcare companies will have to make strategic decisions in order to survive and win (see Figure 4).15

On one axis of Figure 4, we included the conditions and diseases for which consumer engagement will be the main market driver; on the other, we have shown the degree to which standard protocol will guide treatment decisions. In some areas of treatment, both consumer engagement and protocolization will be in play, leading to an opportunity for patient-provider “teaming.” Both of these trends translate into reduced autonomy and decision-making control for physicians for established conditions.

Where there is a high degree of consumer engagement but low protocolization, the patient experience will impact the outcomes most strongly. Such treatment options are often cash-based or lifestyle therapies, like breast implants or erectile dysfunction. Brands will initially rule for these types of procedures because of their familiarity and marketing clout, but prices may be forced down over time as the experience curve is applied to these markets. The degree of protocolization for these therapies will start out weak, but will increase with competition, especially for treating conditions like infertility, where buyers perceive proprietary protocols to be an advantage.

healthcare-2020-fig-04_embedClick to enlarge
The more routine, protocol-driven therapies, such as for conditions like hypertension or procedures for knee or hip replacement, involve processes of care that are generally well accepted, but result in less physician discretion and patient choice. Manufacturers of products for these conditions will need to have good data to accurately price their products and ensure that they are included in any protocols being developed to guide treatment. Whatever patient marketing exists for these types of conditions will largely focus on adherence because care management, not just the specific product, results in better outcomes.

Where there is a high degree of consumer engagement along with a high degree of protocolization for diseases like breast cancer or Type 1 diabetes, manufacturers will need to be sure that they shape the protocols being used and target their marketing to those preferred therapeutic options. The “teaming” between providers and patients will be a significant challenge for payers and manufacturers. In the area of breast cancer alone, the existence of multiple effective patient advocacy organizations will inform patients of their options, and they in turn will put pressure on doctors to find the optimal treatment regimen. Payers will attempt to control the protocol development in this area in order to control costs.

The physician-driven quadrant, with its lower degree of consumer engagement and protocolization, is a “business as usual” state, and there is unlikely to be significant growth in those types of markets. Therapies for migraines or attention deficit hyperactivity disorder (ADHD), for example, have fewer accepted protocols, and thus payers will continue to struggle to control utilization beyond mere cost shifting. New physician-driven therapies will, of course, continue to emerge, but the overall trend is clearly away from full physician control as markets mature and consumers become more involved in their own healthcare.

Over time, more diseases will move up and to the righthand side of Figure 4. Protocolization and consumerism will increase, and payers will demand and use better data about outcomes. Although these changes will not guarantee increased revenue, good outcomes should result in a better share of the profit pool for players that can shape the protocol development by demonstrating how their products create value.

Where can you play—and win—by 2020?

Only transformational business models will enable future winners to capitalize on the disruptive market changes at play (see Figure 5). The models identified in Figure 5 are very different from the business models being discussed in boardrooms today. Becoming a consumer marketing powerhouse, a disease population manager or a successful integrated care company will require different organizational capabilities. For example, for treatments and conditions where the degree of consumer demand is high, like health and wellness programs, or for treatments with high brand recognition, a consumer powerhouse approach can help produce differential growth and market share. For conditions with a high degree of protocolization like hypertension, a population- manager approach may be the answer. The most challenging model of all will be to create integrated care solutions that manage the full suite of products and services across the patient journey. This approach will require deep expertise in patient-centered care and the tools that support that care, such as real-time feedback, secure communication and digital technology to enhance patient participation.

These new approaches require a fresh look across the profit pool for each condition. Here are a few examples to think about:

  • For businesses in the more traditional, physician-dominated quadrants of Figure 4, winners will build the capabilities to deliver risk-sharing models, potentially partnering with payers and providers— or even directly becoming more involved in the delivery of care.
  • If you are operating in the top right-hand quadrant of Figure 4, patient-provider teaming, then you may need to partner or develop capabilities in data sharing and coordination to ”wrap around” the patient and manage a population for a payer or provider organization.
  • If you operate more in the consumer world, you may need to move beyond branding the product and start branding the procedure by forming alliances with certified providers that can perform the procedure or provide medication, such as exclusive, branded and certified botulinum toxin clinics.

healthcare-2020-fig-05_embedClick to enlarge

  • Where the various components of the profit pool have created silos, with products and patients being passed around among them, the trend toward protocolization and consumerization will break down barriers and create a more integrated approach for a given medical condition or procedure. Firms like Fresenius and DaVita are already doing this, and other healthcare companies will either participate in this trend or risk becoming mere commodity suppliers.
  • The industry’s metrics will need to change. Using annual budgets and per person savings will not reflect value adequately for either private or government payers. Can payers stay involved for long-term gain when paying for chronic diseases? Public payers may not be able to resist the pressures to simply reduce their costs. Private payers will need to identify ways to reduce cost and demonstrate improved quality. For providers, it will be a choice of joining the rush to become an integrated care company or trying to find room to be a branded provider of choice.

For a select few, the old models could work—breakthrough innovation will still drive profitable growth, but few, if any, have proven the ability to sustain this over time. Cost pressures will force nearly every company in the industry to rethink how and where it will grow moving forward. Good strategic choices will still yield growth. A profit pool that is growing at a breakneck pace will no longer shelter poor choices. Executives and investors can and must know where the profit pools are shifting—and how they will change course to successfully compete.

George Eliades is a partner with Bain & Company based in San Francisco and a leader in the firm’s Global Healthcare practice. Michael Retterath is a Bain partner based in New York and a leader in the Global Healthcare practice. Norbert Hueltenschmidt is a partner based in Zurich and the head of Bain’s Global Healthcare practice. Karan Singh is a partner based in New Delhi and head of Bain’s Asia-Pacific Healthcare practice.

  1. IMS Institute for Healthcare Informatics, “The Global Use of Medicines: Outlook Through 2015,” May 2011.
  2. The methodology Bain used for developing this profit pool analysis is based on detailed health sector revenue and EBIT margin analysis for US and global sectors. The sector revenues are based and triangulated on latest market reports; the sector margins are based on company annual reports; the 2010-2020 CAGRs are based on market reports, where available, and Bain estimates; and the margin changes from 2010 to 2020 are based on proprietary Bain analysis.
  3. The term “protocolization” refers to the application of proven standards of care and consistent protocols and guidelines to reduce variation in the delivery of healthcare.
  4. Sources: Bain analysis, IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, Centers for Medicare and Medicaid Services (CMS), OECD
  5. Sources: Datamonitor; based on top 50 branded pharma companies
  6. Sources: Business Insights, Datamonitor, analyst reports, Bain analysis
  7. Sources: Business Insights, Datamonitor, Parexel, analyst reports, Bain analysis
  8. Sources: IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, CMS, OECD, Bain analysis
  9. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  10. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  11. Source: Bain analysis
  12. Fresenius Medical Care, “Forward Looking Statements,” 2009, p.31.
  13. Susannah Fox, Pew Research Center’s Internet & American Life Project – Health Topics, February 1, 2011,
  14. “Indians Increasingly Use Internet for Their Healthcare Needs,” Express Healthcare,
  15. Sources: International Guideline Library, National Guideline Clearinghouse data, National Health Service in UK, Medtech Insight and proprietary Bain analysis The methodology for determining the degree of consumer engagement and protocolization in Figure 4 was developed by collecting all the protocols on each disease from a variety of sources, scoring the current level of protocolization on a scale of one to 10 and then adjusting for prevalence and total spending on the disease. For consumerism, we monitored the presence of topics for each disease on a variety of patient websites and corrected for prevalence.

Why health journalists need medical training @kevinmd @drsilenzi @derossire

by  | in PHYSICIAN

I recently followed a brief spat on Twitter between a journalist and a doctor.  It did not go further than a few irritable tweets, but I had to agree with the doctor’s point of view.

The journalist had written an article about the death of a South African shack fire victim, admitted to hospital with 100% burns, and the contrast in perceived care he received compared to that of a lesser burnt victim of the same fire who ultimately survived. A tragic story indeed, but one that repeats itself in principle on a daily basis all over the world where medical needs outweigh medical resources.

The merits of the case are particularly well discussed in the comments section – well worth a read, and especially those made by doctors themselves. I am not going to repeat them, except to say that I agree with them.

But I do want to know how well journalists should be expected to do their job when reporting incidents like this, because there are always many sides to a story, especially one with strong aspects of tragedy. Affected families’ emotions as expected run very high, and in contrast the last thing overworked doctors in an overcrowded facility can afford to be is too emotionally involved.

So where does a journalist’s responsibility lie in reporting the story accurately?  There are many different stories to be told here and in similar situations – of loss and grief, of thwarted hope, of frustration at inability of medical science to heal, of overburdened facilities and healthcare workers, of stark, brutal economic facts that coldly determine who lives and dies.

To do a medical story justice, without taking sides, requires that a journalist knows and understands the issues playing out here, or at the very least makes an attempt to understand them by speaking to people who do know.

The practice of medicine is complex, and when economic realities are added to the mix there is little room for doctors to be emotional, and yet vast opportunity for patients, family members and the journalists who tell their stories to be so.  For a story of tragedy, told with a sense of anger and injustice, is one that is likely to draw more attention and to sell more publications.  That’s unfortunately just the way we humans are.

A story like the one above blames the wrong people and avoids the real issues, which are beyond the control of any of the players themselves. Journalism like this does no one any favors, creating perceptions that are inaccurate, misleading and ultimately unfair.  An editor would not allow someone without financial background or training to write an article on economic strategy or finance, surely?  Why should medicine be any different?

Editors and writers of reputable publications should know that a medium with such broad reach and influence should be used more carefully and responsibly. As apparent “custodians of the truth,” they have an obligation to the public to do so.

Martin Young is an otolaryngologist in South Africa and founder and CEO of ConsentCare.