How do you feel about health-related social networking? Would you join an online health program? What concerns – privacy, quality of service, etc. – do you think this presents?

Read the full text of the Healthcare IT News post here: http://healthcareitnews.com/news/social-media-tools-may-reduce-attrition-online-health-programs

The new apps (FaceDecide & BreastDecide) come in addition to their six existing Orthopedic patient education apps — including an orthopedic app called ShoulderDecide, which was recently reviewed by iMedicalApps.com. While these latest apps are obviously less focused on chronic medical conditions than the original six, they do call attention to just how great the extent of the potential for mHealth seems to be.

In the next few weeks, Orca MD will be rolling out additional features, including an introduction and some infographics dealing with Orthopedic & Cosmetic Surgery. To keep up with these releases, check out their apps, and more, ‘Follow’ @OrcaMD on Twitter, ‘Like’ OrcaMD on Facebook  or check out their YouTube Channel.

Health-related smartphone apps are a relatively recent innovation, and there is no telling what will come. What do you think about the BreastDecide and FaceDecide apps? Would you download them? As the field of mhealth begins to evolve and mature, how do you think apps like this will fare? Do you think these present privacy concerns for users?

I wondered about that as I saw some disparate bits of data over the weekend. An article on Valentine’s Day spending was informative: couples will spend just under $70 on each other and we’ll spend, on average, $5 on pets, $6 on friends, $5 on teachers and $3.50 on co-workers.

What will we be buying? In all, about $12.B in treats for the day: $3.5B on jewelry, $1.6B on clothing, $3.4B on dinner, $1.7B on flowers, $1.5B on candy (of which $285M will be on chocolate) and $1.1B on greeting cards.

I get interested in items like this when I hear that we ‘can’t afford health care.’ I’ve noticed over the years how we can spend more on the launch of a blockbuster movie in a weekend than we spend immunizing our children against measles, mumps and rubella in a year. 

In the past, I might have gone on a rant about that but this weekend another set of statistics caught my eye as well; those related to chocolate. Seems that chocolate-making companies have higher margins than other food companies, raking in 11.7% profits over the 8.1% of others.

Chocolate is a discretionary, luxury item and – though some friends will disagree – not at all essential to a person’s health or well-being, so we need not quibble over those margins, argue for price controls or suggest the industry become a public utility. That same article cited per-capita rates of chocolate consumption, however, which got me to thinking that consumption of chocolate appears to be correlated with two items we care about in health care: expenditures and satisfaction.

Sure enough! Though not a perfect correlation, it’s directionally so. Countries with higher rates of chocolate consumption have lower rates of dissatisfaction with health care and lower per capita health care spending. Wow!  Note in particular the difference between Switzerland and the US. The Swiss eat twice as much chocolate, have a dramatically lower percentage of people who grouse about healthcare and spend nearly half per capita as Americans. 

The policy wonk in me says perhaps we ought to make chocolate a covered benefit and promote its use! And, I’m only half kidding.

Blogger Concetta Tomaino who participated in the December 1st Event is truly a disruptive woman as described in the post below. 

By Hope Ditto. We’re used to our Disruptive Women bloggers being on the cutting edge in their fields and doing amazing things every day. We’re used to them saving lives, fighting for those without a voice and revolutionizing the world around us. Still, it’s not every day that a major motion picture being featured at the world-famous Sundance Film Festival is directly connected to their work.

Not that we’re bragging, but we feel pretty fortunate to call Dr. Concetta Tomaino, D.A., MT-BC, LCAT, one of our own these days. Besides having her work featured in The Music Never Stopped (and having Julia Ormond, the actress playing the music therapist in the movie, consult her on the role), Tomaino is internationally known for her research in the clinical applications of music and neurologic rehabilitation. The Executive Director and co-founder of the Institute for Music and Neurologic Function and Senior Vice President for Music Therapy at Beth Abraham Family of Health Services, Tomaino works tirelessly to bring new understanding to the field of music therapy by working with neuroscientists to determine the effects of music on the brain.

Tomaino and her colleagues use music to treat a myriad of illnesses, injuries and conditions – from Alzheimer’s to Autism, brain injury to mental retardation. At the Institute for Music and Neurologic Function – which she co-founded – music therapists work to treat all of these things and more, using the power of music in different ways and to different effects.

As Connie explained, “For someone suffering from Parkinson’s or recovering from a brain injury, music can be a gateway to speech. They may not be able to speak words, but they often can sing lyrics to familiar songs. Whereas, for a child in the pre-language stage of development, who suffers from say autism or has a mental retardation, we can use music to help them gain an understanding of communication.”

The Music Never Stops is one such success story of music therapy. Based on the essay “The Last Hippie Standing” by neurologist and Beth Abraham colleague Dr. Oliver Sacks, the movie portrays a family coping with their estranged adult son’s grim prognosis following surgery to remove a large brain tumor. Without an ability to discern past from present from future and with little hope for improvement, the father discovers music therapy and seeks out a leading music therapist (a character inspired by Dr. Tomaino’s own work with the patient who inspired the film) known for her success with similar cases. Together, the father and son reconcile through music and memories, and with the help of music therapy. Set in the 1960s and 1970s, against the backdrop of the Vietnam War and the tumultuous protests, the film is culturally, intellectually and emotionally resonant. And apparently quite good, as it was purchased by Roadside Attractions almost a month before its Sundance premiere (full story here).

That’s not the only big news Tomaino and her colleagues are celebrating in 2011. Just recently, there was a major breakthrough in the field of music therapy, when neuroscientists at McGill University discovered that listening to “good” (definition forthcoming) music “changes the chemistry in the brain by boosting the pleasure chemical, dopamine,” (per ABC).

For Tomaino, this was the breakthrough she’d been waiting a lifetime to realize. Not only is her institute’s mission to do just this – pinpoint a medical reason why music heals by determining the effect that listening has on the brain – but it has been her primary focus since undergrad.  

Neuroscience helped to provide the scientific basis for what Tomaino and many others already knew — that music has a unique and awesome power to heal – but, as she is quick to remind you, “Neuroscientists are not the ones doing the treating!” It is music therapists who work to integrate music and other more traditional therapy techniques in order to treat patients young and old. Still, she is excited about this and about the future of the field, which she says is at a crossroads.

“Twenty-five years ago, neurologists couldn’t study music. But in the last five-six years, it has become the hot topic of neuroscience. People don’t believe that the things we say we do here [at the Institute] are possible, but by researching collaboratively [with neuroscientists and music therapists], we are able to prove ourselves, our work and our methodology once and for all.”

The Music Never Stops premieres today (Friday, January 21^st) at the Sundance Film Festival in Park City, Utah. For updates about the film and upcoming opportunities to see it in a theater near you, check out their Facebook page.

In grad school it helped me stay focused – and calmer – through killer statistics classes. Later, it was a way to unwind at the end of a workday. Still later, it saved me from surgery to correct fairly severe scoliosis. It’s not cured the deformity but I’m virtually pain free most of the time – no small feat for one who spends 18-24 hours on flights and 8 hours standing to facilitate meetings.

More disclosure – I am certified to teach, though I don’t. The same erratic travel schedule that prevents attending classes on a regular basis precludes committing to teaching them. I trained to be able to practice on the road. It was a good investment of my time and funds.

Yes, my time and funds. Anyone familiar with yoga knows that for the most part, students pay a small amount for a class – or series of classes – out of their own pockets. Sometimes, yoga is offered in schools, hospitals, churches, workplaces and prisons and the cost partially or fully paid by some third party. Sometimes teachers donate their services as part of the ‘selfless service’ that embodies the lifestyle.

Recent weeks presented an interesting confluence of events in my life as a yoga-practicing health policy analyst: health reform passed and Yoga Journal published a major article on methods, issues, controversies and implications of yoga research.

I started a yoga research literature review a few years ago. It was to be the opening chapter of an adaptation of my grantseeking guide (see www.strategichealthpolicy.com for a free download), revised and updated for yoga teachers intending to seek and secure third-party – including health insurance – financing support for classes.

I abandoned the project for many of the issues raised in the Yoga Journal article: research methods were relatively undeveloped, uncontestable positive results were scant and within the yoga community both were controversial. That’s right, even the need for research to demonstrate the value of yoga is controversial. Many thought there was proof enough.

Proof enough for an individual to pay? Yes, that’s been well-demonstrated. Thousands of times each day, people around the world pay out-of-pocket to attend classes. Proof enough for a third-party to pay? Far from it, at least as we have defined proof within the American health care sector.

Now, the health reform era is upon us, some people will press for yoga services as a covered benefit and if a serious discussion takes hold – and succeeds – in adding yoga to American health care armamentarium, yoga teachers will face issues common to other product and service providers. Clearly, not all yoga teachers will want to participate and none will be forced, but those who choose to do so will need to address – at a bare minimum – questions commonplace to physicians, hospitals and drug companies:

First, is yoga effective? Any prevention or treatment modality used in health care is expected to be safe and effective, demonstrating that it performs as advertised, promoted and hoped.

That means prospective research, such as trials comparing yoga against a non-intervention, a placebo or a standard therapy treatment, or a study of a sufficiently large population through ‘natural observation’ to gather similar evidence over many years.

Research such as this will raise questions about whether the ‘style’ of yoga matters, how many sessions might be required to achieve results and whether results last after classes are stopped. People in the study will be carefully selected and ‘assigned’ to each intervention group. They’ll be asked about other aspects of their lifestyle to assure that they’re not confounding the results with other possibly-effective therapies.

Side effects will be monitored. Injuries in class or suicidal thoughts outside of class (if any occur) will be noted so that cautionary warnings and contraindications can be addressed in coverage and reimbursement decisions. Other unintended consequences – weight loss comes to mind – will be documented but can’t be claimed a benefit unless the study was specifically designed to test for it.

Research might also need to tease out yoga’s “mechanism of action” as is the case for medications; for example, by what mechanism does yoga breathing techniques reduce hypertension?

Researchers will be required to seek approval from Institutional Review Boards protecting patients, may be required to vet research methods with regulators or payers, will likely be required to disclose financial interests in yoga and if any are found might be precluded from doing research and/or might be restricted from committees that address yoga policy and financing issues – all to assure research subjects are protected and conflicts-of-interest are prevented.

Second, is yoga cost-effective? Having passed the first hurdle regarding effectiveness, yoga would then be subject to a test of relative value against other therapies. This will likely be determined by a combination of cost and patient satisfaction factors. Yoga is less expensive than the spinal surgery I faced and I’m very satisfied not to have suffered the projected month of hospitalization, surgical risks and likely post-surgical pain. In fact, had I not learned yoga, even daily classes – were I to pay for them – would likely cost less than the pain medications that might otherwise be a staple of my day and would be immensely cost-beneficial over the disability others in my family have faced.

Could the same be said for hypertension? Generic medications cost only pennies per day and require only seconds to swallow, at far less cost and time investment than a yoga class or daily practice. In fact, even brand products are likewise less expensive and easier to comply with than a regular yoga practice. No therapy is effective – and is certainly not cost effective – if patients don’t use them. Medication adherence can be as low as 50%; are there data to show how yoga compares? If yoga is judged by payers to require more of patients who will not likely adhere to the regimen, payers may be skeptical and reluctant to cover it.

Third, how will yoga teachers and studios be regulated? It’s not a question of ‘whether,’ but ‘how’ requirements will be framed through regulations and provider contracts, and what group will monitor compliance with those.

Products and services reimbursed by Medicaid and Medicare, purchased with federal or state health funds, distributed through the VA, Community Health Centers, Indian Health Service, and Public Health Departments must comply with certain conditions and those will likely apply to yoga as well. Non-government third party payers set their own, similar standards.

Payers want to know they’re financing the activities of legitimate providers of care capable of assuring access and quality at a good cost, adhering to acceptable practices of promotion and protecting against fraud. This will happen through regulation and contractual agreements with providers that will address.

Quality

• Will yoga teachers, as ‘providers’ of health care, be subject to standards beyond those of their training schools?
• Will they be subject to state licensing (as are other providers and facilities), credentialing, periodic re-licensure and re-certifications, continuing education requirements and personal background checks?
• Will yoga teachers be required to collect and report injuries or adverse events sustained during classes, as do hospitals or pharmaceutical companies in reporting injuries and adverse events? If so, will those be published in increasingly-familiar formats like report cards on providers?

Access

• Will yoga studios, as a ‘setting’ of health care, be subject to requirements for access for special populations such as children, seniors and the disabled?
• Must yoga address non-financial barriers (e.g., language)? Government-funded providers must treat patients in their language – providing translators if needed. Must yoga teachers do likewise?

Cost

• To control for appropriate use, will a prescriber order be required, much like for physical therapy?
• Will the number of reimbursed yoga classes be limited, much as other visits for psychotherapy or physical therapy?
• Will payers require pre-authorization for yoga classes, such that the prescriber or yoga teacher will need to justify a prescribed number of classes, or additional classes for some patients?
• How will the fee for a yoga class be set? Will the rates be negotiated? Or set by the payer?  Will government get the ‘best price’ through rebates, competitive bidding, volume purchasing or price controls?
• If only a portion of the class fee is paid by a third party, may teachers collect the difference from the student/patient, or as in Medicare will they be prevented from doing that?

Marketing and Promotion

• How may yoga be marketed and promoted?
• Can claims be made for health outcomes without clinical evidence to demonstrate its validity? What endpoints are satisfactory to prove the claim? For example, is ‘toning muscle’ or ‘developing balance’ a satisfactory endpoint or must reductions in hip fractures from falls be demonstrated?
• Can one form of yoga claim superiority over another, and if so, under what criteria and circumstances?
• Must all promotional claims also include a list of possible injuries to assure ‘fair balance’ or ‘informed consent’ and clear warnings to patients?
• Will promotion to health care providers be allowed and if so, of what type? Sampling? Reminder items? Continuing medical education?

Fraud Protections

• Will yoga teachers be required to transmit class attendance information and provide progress reports to payers that provide coverage and reimbursement?
• Are payers entitled to know how often – and with what results – patients attend classes?
• Will yoga providers be required to link class attendance to electronic personal health/payment records?
• How will payers audit records to assure that billing matches the actual class attendance by covered patients?

Some payers – as businesses do now – may choose to offer yoga and never address the issues raised here. In my own company, for example, having seen the value for myself, I’d gladly underwrite the cost for my employees. The same might be true for even a very large company.

If yoga ‘goes mainstream’ in health care, however, it is likely that it – and other ‘alternative’ modalities – will be scrutinized. I know both sides and can envision a dozen questions more than the ones posed here.

It’s not my place to say what is best for yoga in America, its students and teachers, or what’s best for health care in America, its patients or payers.

A match made in heaven? It’s too early to tell. Time will. OK everyone, relax, take a deep breath….and another….

This past week, I ran across a study in Menopause that not only supports this contention but also challenges us to more closely examine the limitations of current investigations into alternative therapies.

ACUFLASH (the Acupuncture on Hot Flashes among Menopausal Women Study) was a randomized, controlled, parallel study comparing the efficacy of weekly acupuncture plus self-care to self-care alone in 277 menopausal women experiencing, on average, 7 or more hot flashes daily. But here’s the rub: unlike previous trials, ACUFLASH actually estimated the effectiveness of acupuncture in practice, meaning that the study was specifically designed to mimic the basic tenets of Eastern philosophy and incorporate the subjective. Consequently, after agreeing upon expected diagnoses and recommended point selection, licensed Traditional Chinese Medicine acupuncturists were free to diagnose, select acupuncture points and individualize treatment for each study participant.

Not only did the mean frequency of hot flashes decline at least 50% in half of women receiving acupuncture plus self-care, but significant improvements were also noted in hot flash intensity and overall quality of life measures. More importantly, by incorporating a larger study group, and eliminating sham needles and “standardized” (compared to individualized) practice, the researchers were better able to preserve the overall quality of acupuncture and what it strives in achieve, while still remaining true to the tenets of evidence-based scientific methodological standards.

Is this study without flaws? Certainly not. Indeed, the investigators acknowledge that the study participants were not treatment naive, and point out that sham acupuncture, which may be necessary for a true comparative analysis, is hardly “physiologically inert.” Nevertheless, I remain hopeful that the study design and its positive results may open the alternative therapy door a bit wider and lend further credence to its role in treating disease.