Archive for Tom Emerick

Simpson’s paradox and health care transparency

Simpson’s paradox occurs when data show the opposite of what is really true. That happens what there are “lurking variables” for which adjustments have not been made. Statisticians and experts in Six Sigma know this phenomenon well.

Health care “transparency” can lead to an abundance of Simpson’s paradoxes. The best surgeons may have low scores. The Health Care Blog, one of my favorites, has a story by SAURABH JHA, MD, illustrating how Simpson’s paradox occurs in comparing data on surgeons.

You can try to adjust for patient mix all you want but surgeon scorecards should be taken with a big grain of salt.

In my career, I’ve participated in a number of initiatives to provide healthcare transparency to consumers. They all fell short…Simpson’s paradox.


Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.

Coffee—drink up

This is taken from The Doctor Weighs In post by Dov Michaeli.

Per the article, “Coffee drinkers have a reduced risk of dying prematurely from all causes, and consequently live longer.”  Coffee is a “vice” that is most worthy and one to be embraced.

Some health attributes of coffee include reduced risks of death from:

  • Cardiac arrhythmia
  • Type 2 diabetes
  • Dementia
  • Pneumonia
  • Lung disease
  • Accidents
  • Strokes
  • Etc, etc

That’s quite a list. The good news is that a 50 cent cup of coffee works as well as a five dollar cup. Any amount of coffee is better than none. According to results of a study by the NIH, “Compared with people who drank no coffee at all, men and women who drank six or more cups per day were 10% and 15% less likely, respectively, to die during the study.

Don’t tell wellness true believers about this. They may want to start charging coffee-free employees a higher health payroll deduction.


Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.


Study casts doubt on breast cancer testing

The Guardian carried a story by Sarah Boseley about the controversy in Europe and other countries about the effectiveness and safety of mammograms. It seems some of the early studies on this were deeply flawed.

Per the article, “Internationally renowned cancer experts have cast fresh doubt on the benefits of breast cancer screening programmes, warning that they save fewer lives than previously thought.”

Says Professor Julietta Patnick, an expert on breast cancer, “…there are potential risks as well as benefits associated with breast screening, including over-diagnosis, and it is important that women are given information that is clear and accessible before they go for a mammogram.”

She calls for women to have truly informed consent so they can decide to have a mammogram or not.

This is a controversial area. Should employers be involved in promoting this and prostate screenings? I’m not so sure.

Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.

Tips on evaluating a wellness program

This is news you can use.

If you want to evaluate the cost/benefit ratio of a wellness program, the following is a list of costs that are almost always overlooked in wellness evaluations. These are not the only things that need to be evaluated, just the ones most commonly overlooked.

When the items in the following list are fully considered, wellness evaluations can look entirely different.

  1. The cost of staff hired to manage the program. A rule of thumb is to multiply their salary times 2 to account for FICA, benefits, office space, training, workers comp, management, etc.
  2. The cost of wages for workers attending wellness events at work. One company I looked at was spending about $175 per employee per year on this, not a trivial sum.
  3. The opportunity cost of the HR staff running the program.
  4. The full cost of wellness communications. Sending wellness communications to people at work has a wage cost. See #2 above.
  5. The total cost to evaluate the program periodically.
  6. The cost of false positives caused by sending employees to doctors when they’re not sick. This is especially pernicious if you’re paying for wellness exams for employees. At one company the cost of the false positives, sometimes as high as $80,000 per event, nearly cost more than the physical exams themselves. You have to examine claims data to see this.
  7. If you have a fitness center, you need to take into account sports injuries for users. This involves access to claims data. I’ve evaluated the impact of fitness centers for three very large companies. Taking into account sports injuries, etc, your could not make the case for an ROI for any of the three of them. In one company, we examined claims data on a) moderate or occasional fitness center users, b) people who used the fitness center regularly, and c) non users.  Non users had the lowest average medical costs. Moderate users had higher medical costs than non users, and regulars users had the highest medical costs, a perfect reverse correlation.

Surveys of employees are notoriously unreliable. They measure employee opinions at best, but opinions are not facts. As we all know, sometimes in employee surveys people will say what they think the surveyor wants to hear.

Medical claims and sick pay data are about the most meaningful ways to measure wellness outcomes. Short and long term disability data can be useful too, as can life claims experience when compared to norms. If you only use employee surveys/HRAs and other surrogate data, too bad.

I met an actuary who spoke at a conference on this topic and used the measurements above to evaluate wellness programs. He said he’d never seen one that had a positive ROI, except ones that used payroll deduction penalties.

Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.

Victims line up for cancer doctor’s sentencing

The Detroit News carried a story by Laura Berman about the sentencing of a rogue doctor named Farid Fata, who diagnosed patients with cancer when, in fact, they did not have cancer. He gave them massive doses of chemotherapy which killed many of them. It seems there were about 550 victims…all for profit.

He was a kindly looking person. He probably had a good beside manner, too, and may have been well-liked by his victims. But he was a medical monster.

Writes Berman, “Fata has been compared by government lawyers to financial fraudster Bernard Madoff for the brazen scope of his crimes and his willingness to prey on those who trusted him. At least two expert medical witnesses for the government are scheduled to testify during the sentencing hearing.”  That is a bit of an unfair comparison as Madoff was stealing money, but not killing people.

But like Madoff, some people in Fata’s office had to know what was going on. Why aren’t they going to jail too?

When benefit managers and their consultants demand networks with the most providers, this is one result.


Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.



Should we worry about getting cancer?

This is the title of a fascinating article in The Doctor Weighs In by Dov Michaeli, MD PhD.

Some of the most dreaded words we can hear from a doctor are, “You have cancer.” Many Americans have a phobia about that. The term is cancerophobia. Cancerophobia can lead to “…repeated medical examinations, without being able to be reassured for any length of time.”

Writes Dov, “Most of us are not overtly phobic about cancer, but it is always lurking deep in our subconscious. Why is it not an active fear? The simple answer: because in all likelihood it isn’t imminent.”

According an article in Science by George Klein,…“two out of three people will never be impacted by cancer. Even the majority of heavy smokers, who bombard their lungs with carcinogens and tumor promoters over many years, remain cancer free.”  Further while most men over age 60 have microscopic cancer cells,“only a small minority of these cells develop into secondary tumors.”

So, should we not worry so much about getting cancer? Per Dov, “That’s not a productive question to ask.”

For me? I’m going to try to live a happy and productive life, avoid cancerophobia, have few regrets, and not worry about what’s going to be written on my death certificate in the end.


Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.

Optimism and longevity

Dov Michael wrote an informative article on this topic. (Hats off to The Doctor Weighs In) Optimism  provides a mortality advantage. Optimists live longer than pessimists it seems.

Writes Dov, “There is real scientific evidence, accruing at an accelerating rate, that optimistic disposition leads to better health; the converse is true for pessimism.”

Optimists are twice as likely to be in ideal cardiovascular health, according to a new study led by Rosalba Hernandez, a professor of social work at the University of Illinois.”

In recent posts we’ve explored how loneliness is a killer, as is anger. Resilience is important to longevity too.

Problem is your doctor can’t do much to make you more optimistic. in fact sometimes they inadvertently do the opposite. They can’t make you a less angry person nor a less lonely person.

In many ways your health is too important to trust to a doctor.



Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.



ACA enabled health insurance cooperatives suffer huge losses

According to a WSJ article (subscription required) written by GRACE-MARIE TURNER and THOMAS P. MILLER, ACA enabled health insurance cooperatives “suffered an estimated $377 million in net underwriting losses.” Whoa! That’s big.

One cooperative has closed down completely and others will need massive subsidies to survive.

Why?  “…most co-ops have significantly underpriced premiums and grossly underestimated medical claims. Many seek significant premium increases for 2016: 58% for individual plans in Utah, 38% in Oregon and 25% in Kentucky, for example.”

Further, “Iowa’s CoOportunity Health…was the first to confront the hard reality of insurance economics as medical claims far outpaced premium income. After the co-op burned through $145 million in federal loans, an Iowa state court in February ordered the organization to be liquidated”… creating yet another layer of tax burden for taxpayers.

Designing a health insurance plan is easy. The hard part is pricing it correctly. That’s why actuaries make big bucks. Why in the world did anyone think amateurs could do a better job of running and pricing health insurance, a most complex and nuanced endeavor, than health insurers?  The co-ops just foolishly underpriced the premium rates. Period.


Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.


Guest article on future of nurse practitioners by Kathleen Bartholomew, RN, MN

The article below was written by Kathleen Bartholomew, RN, MN, who is one the most popular guest writers for Cracking Health Costs.  In this artifice she describes the coming shortage of primary care doctors and how nurse practitioners are well suited to fill in many of the gaps.

Tom Emerick

NURSE PRACTITIONERS: The Time Bluff by Kathleen Bartholomew

Anyone I’ve ever met who has been treated by a Nurse Practitioner is extremely happy with the care they have received. And as a nurse, I’ve heard numerous stories from family and friends that all drop a reference about the amount of time that an NP spends with a patients vs. the typical physician interaction. Is this observation Reality or Perception?

The vast majority of studies about Nurse Practitioners come from the UK and are a decade old. Even then, the last study which involved time amounted to four minutes more with an NP. But a lot has happened in the last decade in America. What do we know?

“Patients now spend more time with physicians, not less, than they did 20 years ago. The average length of visit to a physician in 2006 was 21.8 minutes; in 2002, it was 18.4 minutes and in 1989 it was 15.9 minutes”(1) Yet people constantly state that doctors are spending less time.

The autonomy that NP’s have today has allowed many to spend the amount of time they deem needed with their patients- especially in hospice, oncology and palliative care or when working closely with a physician partner. But there are also just as many NP’s who have watched the amount of time they have spent with patients steadily decline with each year.

Melanie is an NP who used to spend 45 minutes with each patient. Now, she laments, “The corporate expectation is 20 minutes, but in reality, I spend 15 minutes charting and only 5 minutes hand’s on.” The clinic in which she works needed to ramp up their efficiency in order to generate more revenue – yet patient satisfaction remains high and these patients keep returning for their five minute encounter. Anecdotal? Hardly. She works in one of 600 clinics. What is going on here?

Is the time an NP spends with a patient relevant if the outcomes are par? In our culture, time is equated with caring. Patients feel that NP’s care about them for a few very good reasons.

Physician training has not changed significantly over the years- education has been historically diagnostic and focused on treating symptoms. What is the problem and how can we fix it? With the increase in chronic disease, obesity and diabetes, diagnoses is more challenging than ever. This is not to say that physicians do not care! It’s just that the mental model from which they practice asks for facts more than circumstance, and data more than story. The result? Patient’s perceive NP’s care more and that equates to spending more time with them whether fact or fantasy.

NP’s have a broader theoretical framework based on caring that emphasizes relationships, wellness, and discovering the cause of illness. The words chosen and manner in which an NP asks questions are founded in holistic nursing principles. Why do you think your blood pressure has gone up lately? Last time I saw you, you were worried about your daughter – how is she? The perception from the patients POV (point of view) is that NP’s care because their words validate context, relationships, and thereby demonstrate caring.

There will be a shortage of 60,000 primary doctors by 2025. We need more research for both NP’s and Physicians so that we can both learn how to best help our patients change their behaviors. Perceptions not need match reality, but the current perception gives NP’s the upper hand.

1. (National Ambulatory Medical Care Survey, CDC’s National Center for Health Statistics.)





Are You at Risk for a Heart Attack After Exercise?

This is the title of a WSJ article written by Ron Winslow (subscription required).

Writes Ron, “…rigorous exercise, whether on a treadmill, a road race or a basketball court, does elevate risk for sudden cardiac arrest, a typically fatal event that can be triggered by a heart attack…”

While there is an abundance of data showing the advantages of regular exercise, “ ‘Exercise is not a vaccine against heart disease,’ says Michael Joyner, an exercise physiologist at Mayo Clinic, in Rochester, Minn.” (emphasis mine)

Wellness vendors need to show a much more balanced point of view regarding vigorous workouts. They pose a risk, even if a small one.



Tom Emerick

Watch for Tom’s latest book coming to Amazon soon: An Illustrated Guide to Managing Your Health—HOW TO IMPROVE YOUR HEALTH IN 40 COMMON SENSE STEPS.