There has been a lot of controversy in health policy circles recently about hospital market consolidation and its effect on costs. However, less noticed than the quickened pace of industry consolidation is a more puzzling and largely unremarked-upon development: hospitals seem to have hit the wall in technological innovation. One can wonder if the two phenomena are related somehow.
During the last three decades of the twentieth century, health policymakers warned constantly that medical technology was driving up costs inexorably, and that unless we could somehow harness technological change, we’d be forced to ration care. The most prominent statement of this thesis was Henry Aaron and William Schwartz’s Painful Prescription (1984). Advocates of technological change argued that higher prices for care were justified by substantial qualitative improvements in hospitals’ output.
Perhaps policymakers should be careful what they wish for. The care provided in the American hospital of 2013 seems eerily similar to that of the hospital of the year 2000, albeit far more expensive. This is despite some powerful incentives for manufacturers and inventors to innovate (like an aging boomer generation, advances in materials, and a revolution in genetics), and the widespread persistence of fee for service insurance payment that rewards hospitals for offering a more complex product.
Technology junkies should feel free to quarrel with these observations. But the last major new imaging platform in the health system was PET , which was introduced into hospital use in the early 1990’s. Though fusion technologies like PET/CT and PET/MR were introduced later, the last “got to have it” major imaging product was the 64 slice CT Scanner, which was introduced in 1998. Both PET and CT angiography were subjects of fierce controversy over CMS decisions to pay for the services.
Continue reading “Hospitals’ Twenty First Century Time Warp”
Filed Under: THCB
Tagged: Costs, device regulation, EHR, Hospitals, Innovation, Jeff Goldsmith, market consolidation, Tech
May 21, 2013
Monday’s massive tornado ripped through Moore, a suburb of Oklahoma City, devastating homes and businesses and killing at least two dozen people. The disaster came just over a month after an explosion at a fertilizer plant devastated the town of West, Texas, killing 15 people and injuring some 200 others. Just two days earlier the bombings at the Boston Marathon left three dead and more than 260 injured.
Three mass mass-casualty events occurring in three very different settings show that disaster preparedness should not be limited to large cities or “target” areas in the United States. One trait that is common to all such events—whether urban, suburban or rural—is the need for coordinated, responsive trauma care for victims.
Boston had an advantage over the rural community of West in that seven hospitals, including facilities with readily available, highly specialized trauma and burn care, were in close proximity to the site of the blast. In contrast, the majority of casualties in West had to be transported to hospitals in Waco, 20 miles away. The main receiving facility, Hillcrest Baptist Medical Center, is a hospital with trauma care capability. Other victims were treated at Providence Hospital, which is not a trauma center, and Scott & White Memorial and McLane Children’s Hospital in Temple, Texas, about 50 miles away. Several patients were transported as far as 75 miles to Parkland Hospital in Dallas, the closest facility with burn and highly specialized trauma units. Most of these victims had traumatic injuries. In the case of Moore, the tornado inflicted significant damage to Moore Medical Center, requiring 145 casualties, including 45 children with minor to severe injuries, to be taken to other area hospitals in and around Oklahoma City.
Continue reading “From Boston to Oklahoma -Lessons for the Regional Trauma Response System”
Filed Under: THCB
Tagged: disaster preparedness, Emergency Medicine, Mashid Abir, Rand, Regional Trauma Centers, Stewart D. Wang, The States, Trauma Response
May 21, 2013
What if the next time you step into your doctor’s office for an examination, she reaches into her white coat pocket and pulls out an iPhone instead of a stethoscope? That’s the idea behind The Smartphone Physical, a re-imagination of the physical exam using only smartphones and a few devices that connect to them. These include a weight scale, blood pressure cuff, pulse oximeter, ophthalmoscope, otoscope, spirometer, ECG, stethoscope, and ultrasound. Want to know more? I’ve answered some questions here for THCB. And have a few myself.
What are the pros and cons of using smartphones for clinical data collection?
Smartphone penetration in virtually every market has exceeded expectations, and healthcare is no exception. More than 80% of physicians in the US have smartphones, and of those three-quarters use them at work. Much of this is currently personal communication, but increasingly physicians are using smartphones as reference tools; between 30-40% report using their smartphones for clinical decision support. It seems like a logical next step to go beyond reference apps and to start using peripheral devices, such as cases that convert the smartphone into an ECG or otoscope as well as peripherals such as pulse oximeters and ultrasound probes, for easy and reliable data collection.
At TEDMED we found that using our smartphones and the clinical devices actually improved our ability to engage with the “patient,” because we were able to share and explain the physical exam findings directly at the point of care. We could take a quick snapshot of the carotid arteries and tympanic membrane and, for the first time ever, show the patient what theirs looked like and field any questions they may have. Ideally in the near future we’d be able to go one step further and upload this data to the patient record. That is one of the most powerful aspects of the Smartphone Physical because we will be able to establish baselines for individuals. For example, instead of the current model of a primary care ophthalmologic exam, where a physician will write “W.N.L” or “unremarkable” for a patient without a concerning optic disc finding, we will be able to take and store an actual image of what the patient’s optic disc looked like at an earlier time-point. This may be particularly useful for patients who present years later with concerning visual changes.
Furthermore, smartphone-based collection of clinically-relevant data will help patients become their own data collectors. This may abstract away the mundane and standardize the unreliable aspects of the physical exam, and allow for trending data that needs to be taken in context and not just at once-yearly visits (e.g. blood pressure, temperature, etc).
Continue reading “The Smartphone Physical”
Filed Under: THCB
Tagged: Apps, mHealth, Screening, Shiv Gaglani, Smartphone Physical, TEDMED 2013
May 20, 2013
Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home for the simplest of reasons: home was where they needed care.
By the mid-1980s, the pressures of time and money prevented most physicians from making house calls anymore. But I kept seeing patients at home until I retired from my practice after 29 years. Home visits enabled me to better detect, diagnose and treat most health conditions. Many of the patients I saw might otherwise have wound up in an emergency room and eventually been admitted to a hospital.
If we hope to rein in health care costs and improve quality, we need, in effect, to bring back the house call. Americans are living longer than ever before and a higher percentage of the population is elderly, with both trends sure to accelerate drastically in the decades ahead. Baby Boomers are now turning age 65 at the rate of roughly 10,000 per day.
As the older demographic expands, so, too, does the number of people who live with chronic diseases, chiefly diabetes, high blood pressure and heart failure. About three in four of Americans age 65-plus suffer from more than one such chronic condition. The single biggest and fastest-growing contributor to healthcare costs is chronic disease. That’s why an estimated, 49% of our health care costs go toward 5% of Medicare beneficiaries.
Yet the U.S. health care system is still based on a massive misconception: that health care for the sickest of the sick, typically the elderly and the chronically ill, should be carried out almost exclusively in institutions, primarily hospitals, but also nursing homes and assisted living facilities. And that health care delivery should consist largely of, say, a trip to the emergency room or a four-day hospital visit for pneumonia. That kind of episodic engagement represents short-term thinking. When it comes to health care, hospitals are essential, but are only a part of the answer.
Continue reading “Bringing Back the House Call”
Filed Under: Physicians, THCB
Tagged: Home Health Care, Hospice, Long Term Care, Michael Fleming, Patient-centered care
May 20, 2013
Last week, CMS unilaterally released chargemaster data from 300 hospitals around the country. As David Dranove summed up well in his recent piece, this is an old hat. Yes, there are big variations in hospitals’ chargemasters. And yes, there is a lot of buzz around consumer price shopping.
A Kayak for hospitals is all well and good, but hospitals are cash-strapped as it is and there is only so much money to be saved by driving down the costs the hospital charges the health care plan unless the waste within the hospital is addressed. I would like to highlight perhaps one of the most exciting things going on under the radar in US healthcare today: using price transparency data within the hospital.
Hospitals are now reimbursed a capitated amount according to each patient’s diagnostic-related group. Capitated payment means, essentially, that the hospital receives a set amount of dollars for each patient that walks through its doors with a given diagnosis — say, $X for a patient with pneumonia or $Y for a patient with MI. Regardless of how many drugs, tests, or scans the hospital uses for the patient, it will still get the same compensation from the insurance company.
Yet, the physician up until now still acts as a kid in a candy store, running up a bill without awareness of cost or value. This is largely because the doctor is ordering from a menu without prices. I have talked to many physicians, in both out-patient and in-patient settings across seven health care systems around the country — they want a menu with prices.
I have seen firsthand the motivation for this, as pay-for-performance model is beginning to take over with my own practice. Gone are the days where doctors’ salaries are unhitched to the cost-effectiveness of care. Everyone is now in the same boat.As a neurologist, I want to share a few examples regarding stroke care that illustrate the potential savings available from educating physicians regarding cost, and also some pitfalls to avoid that could compromise patient care.
Continue reading “Using Price Transparency Data Within the Hospital”
Filed Under: THCB
Tagged: Costs, David Halpert, Hospitals, pricing data, Transparency
May 16, 2013
“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.
“Wal-Mart’s in retail, we’re not in health care.”
But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.
Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.
Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.
Background: Wal-Mart’s Growing Role in U.S. Health Care System
In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.
“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”
And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care. Continue reading “Wal-Mart Could Transform Care–But Does It Want To?”
Filed Under: THCB
Tagged: Access, Affordable Care Act, Dan Diamond, Quality, Retail Clinics, Walmart
May 15, 2013
HealthPartners argues that the answer is yes. In a 2013 Health Affairs article, they argue the following:
HealthPartners in Minnesota launched an online clinic called virtuwell in late 2010. After more than 40,000 cases, we report an average $88 lower cost per episode compared with care received in traditional settings, strong indicators of clinical effectiveness, and a 98 percent “would recommend” rating from customers. The possibility of extrapolating such savings to larger volumes of cases is compelling.
Although I believe that there will be some savings from online health clinics, I believe that much of this perceived savings is due to patients sorting. If relatively healthier patients use the online health clinic, then it could be the case that average costs will be lower for those who use the online services simply due to patient sorting. The report does risk adjust for patient comorbidities and other factors.
Risk adjustment, however, is always imperfect. Thus, three confounding factors could bias these estimates.
- Individuals who are more educated, wealthier, more technologically savvy are more likely to use the online health clinic, but are also more likely to be relatively healthy conditional on observables.
- Individuals who use the online clinics may be more likely to seek treatment for less severe cases. If this is the case, then the treatment received during the online clinic may appear cheaper than is really the case since treating this same people in the clinic may have been cheaper than the average patient. Thus, there would still be cost savingings but the magnitude would not be as large.
- Whereas the points above mention that there could be differences in the types of patients that use the online services, within each individual preferences for online treatment may vary. The less serious an illness appears to be (i.e., the lower the likelihood urgent care is needed from the patient’s perspective) the more likely individuals will seek online care.
Continue reading “Is the Online Health Clinic the Wave of the Future?”
Filed Under: THCB
Tagged: FutureMed, HealthPartners, Jason Shafrin, online clinics
May 14, 2013
There are two definitions of the word “Hacker”. One is an original and authentic term that the geekdom uses with respect. This is a cherished label in the technical community, which might read something like:
“A person adept at solving technical problems in clever and delightful ways”
While the one portrayed by popular culture is what real hackers call “crackers”
“Someone who breaks into other people computers and causes havok on the Internet”
People who aspire to be hackers, like me, resent it when other people use the term in a demeaning and co-opted manner. Or at least, that is what I used to think. For years, I have had a growing unease about the “split” between these two definitions. The original Hackers at the MIT AI lab did spend time breaking into computer resources… it is not an accident that the word has come to mean two things.. It is from observing e-patients, who I consider to be the hackers of the healthcare world, that I have come to understand a higher level definition that encompasses both of these terms.
Hacking is the act of using clever and delightful technical workarounds to reject the morality embedded default settings embedded in a given system.
This puts “Hacking” more on the footing with “Protesting”. This is why crackers give real Hackers a bad name. While crackers might technically be engaged in Hacking, they are doing so in a base and ethically bankrupt manner. Martin Luther King Jr. certainly deserves the moniker of “protester” and this is not made any less noble because Westboro Baptist Church members are labeled protesters too.
Continue reading “Hacking Healthcare”
Filed Under: THCB
Tagged: Data, e-patients, Fred Trotter, Hacking Healthcare, Health 2.0, Health: Refactored
May 14, 2013
It really shouldn’t be this hard. This doesn’t seem like rocket science, but you keep telling us it is. What’s the deal with the passwords? Why can’t computers at different hospitals talk to each other? What’s the story with the obsession with mindless data entry? Have you ever tried using one of these things? Harvard’s Shirie Leng speaks for a growing chorus of annoyed EMR users.
Nobody would argue that opening up hospital prices is a bad idea. After all, it’s pretty hard to shop around when you don’t know how much what you’re shopping for costs. So opening up hospital price lists is a logical thing to do. But people who argue that giving the public access to this information without context will change anything are guilty of deeply flawed magical thinking, argues David Dranove.
Larry and Lincoln Weed’s 2011 exhaustive study on the problems facing the healthcare system and the ways technology might be able to help solve them did not exactly get the attention many more talked-about and hyped titles on health reform and the business of healthcare do. A pity that their sensible and timely book has largely been ignored by critics, writes THCB contributor Leslie Kernisan. Many of the ideas the Weeds discuss, such as the Problem Oriented Medical Record (POMR) and the need for a better way for physicians to manage their decision-making, are well worth our time.
Critics looking at this months Oregon study are getting a bit carried away in their rush to weigh on the unbelievable significance of what it all means, writes Harvard’s Ashish Jha. The initial reaction served as a “Rorschach test,” reflecting critics’ view on Medicaid” which shouldn’t really have surprised anybody. The reality is a little more complicated. Actually, make that a lot more complicated.
Nonsense, writes THCB contributor Mike Miesen. The Oregon experiment may turn out to be the most important public health study in decades, if not in history. “Get ready for bombastic claims and scorching heat as opposed to illuminating light.” We finally have solid data that lets us understand what’s happening. And that’s a very good thing.
You heard it here first. Doctors are going to need all sorts of special skills to survive in the future. A growing number of medical schools are experimenting with novel approaches designed to attract brilliant candidates with experience outside of the traditional science focused areas.
Ezra and Silas. Two births. Two very different stories. After their obstetrician pushed for an early delivery when David Overton’s wife was pregnant with the couple’s son Ezra, the healthcare insider began asking questions. When their son Silas was born, they took the opposite approach, hiring a midwife to help them through the process using an all-natural, all “granola approach.” The two experiences could not have been more different. What was happening here?
In American society more is generally considered better. The result: health care costs more than anywhere else in the world. There is a better a way. And doctors have it in their power to do something about it. THCB contributor Rob Lamberts offers his house rules for winning the “war against more.” Never order a test that doesn’t help you decide something important. Never send a patient to a specialist, unless they need. Never prescribe a drug without telling the patient. And, well, if you want to know how the story ends you’ll have to read the whole thing for yourself…
Playing Games(MMORPGS), Massively Open Online Courses (MOOCs) like the Khan Academy have become one of the latest obsessions in the tech industry. That led Eric Topol to playfully suggest that the time may be right for Massively Open Online Medicine.(MOOM). That may not be a good thing.
The news the Patient Privacy Rights Coalition had appointed a chief technology officer caused a minor stir. After all, the Austin-based non-profit organization has a long history of challenging the tech industry at almost every turn, raising awkward (read highly annoying) questions about the EMR vendor practices, companies privacy policies and questionable use of data. In a THCB commentary, CTO Adrian Gropper talks about what it all means. Could a thaw be coming. Does the news signify that new era of peace, love and understanding is at hand? Probably not.
Continue reading “Top THCB Blog Posts of the Last Two Weeks”
Filed Under: THCB
May 13, 2013
There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber. Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father. Why not hire someone to come fix it? I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet. So this hole was giving me shame in surround-sound.
I attempted to fix it the hole last year, even going to the degree of asking for a router table for my birthday. Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly. Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.
I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!
This home project is actually a late comer to the DIY party I’ve been holding for the past few months.
- Don’t like your practice? Build your own from scratch!
- Don’t like the health care system, build a new one!
My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.
Continue reading “The DIY Electronic Medical Record”
Filed Under: OP-ED, THCB
Tagged: EHR, practice management, primary care, Rob Lamberts
May 13, 2013