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A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below).  In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled.  Let’s focus on two consistent distortions.

Evidence-based Medicine (EBM).  Few are opposed to evidence-based medicine.  What’s the alternative? Ignorance-based medicine? Hunches?  However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about  12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients.  Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable. 

Relative vs. Absolute Drug Efficacy:

Let’s talk a tiny bit about arithmetic. Say we have a medication (called  X) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time.  Not great, but not atypical of many medications.  Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects).  But what does the advertisement for drug “Newbe” say?   That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie.  Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist?   

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I’ve never met the man, and I don’t mean this personally, but Florida Gov. Rick Scott is an idiot.  Rather, more specifically, the way he has managed Florida’s Medicaid expansion, or lack thereof, is idiocy on the altar of political ideology and kneejerk Republican healthcare doctrine.   

Other governors are fighting Medicaid expansion, of course.  It’s a major battleground in the implementation of the Affordable Care Act (ACA).  But Scott, 62, and governor since 2011, has raised his resistance to the level of high political theater that defies commonsense and hurts Florida residents.

If you haven’t been following this lately, here’s a quick recap: In April, Scott filed suit against the federal government (HHS) over federal funding for a special Florida program, launched in 2005, called the Low Income Pool (LIP). The funding—due to be about $1.3 billion in 2015-16 and combined with about $1 billion in state funds—compensates safety-net hospitals for care of low-income, uninsured people.  It’s set to expire on June 30 and must be reauthorized by HHS. 

Scott and Florida claim in the suit that HHS is trying to force the state to expand Medicaid against its will and in violation of federal law—that law being the now-famous 2012 Supreme Court decision that gave thumbs up to constitutionality of the ACA but nixed the law’s mandate requiring states to expand Medicaid.  Medicaid expansion is thus voluntary.  (A half dozen or so Republican governors who were initially opposed to Medicaid expansion have relented; the most recent are in Utah and Missouri. To date, 29 states plus DC have expanded Medicaid under the ACA and 17 have not.  In four states, including Fla, it’s being debated.)    

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I was incredibly impressed by the announcement this week that three top U.S. health systems – Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan Health System – will be enforcing standards that prevent low-volume hospitals from performing certain surgeries.

This comes on the heels of a major U.S. News story which showed that patients who had surgeries at low-volume hospitals faced significantly higher risks of complications and death.

The data itself is not surprising. The relationship between low procedure volume and worse outcomes has been well documented since a first major publication on the topic in 1979.

It’s also common sense. The more times you perform a procedure, the better you will be at it. If you’re only performing a hip replacement surgery 3 times a year, chances are you won’t do it as well as a surgeon who performs 200 a year. Practice makes perfect.

Instead, what’s surprising is that these three major medical systems are putting their feet down, even though they don’t need to.

There’s no Obamacare incentive. In fact, this decision could cost these health systems a lot of revenue. And this will certainly upset some surgeons and staff who want to keep performing those surgeries.

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Rachel Katz OptimizedLisa is an administrator at an Accountable Care Organization, or ACO — a new healthcare payment model that encourages coordinated, high-quality, and efficient care. Lisa’s ACO facilitates the program at about 100 clinics around California, and her mission in the first year of operating might seem elementary to an outsider: to report a set of metrics to Medicare that indicate the health of patients who had been seen at these clinics.

At the start of 2015, Lisa received a panel of patients to review. She had expected a list of about 600, but instead there were 2,400. For each, she needed to report on a specific outcome or physician practices — like which beneficiaries with hypertension had blood pressure less than 140/90 and which had been screened for a risk of falling.

The kicker: she had just six weeks to submit this data. Most of the clinics didn’t have staff to do the required reporting, so Lisa contracted an assistant to travel from clinic to clinic, collecting the information they needed. About a quarter of the clinics used paper records, so the pair of administrators leafed through stacks of paper charts for the blood pressure and screening data.

In six weeks, Lisa collected 2,400 data points from across the clinics and submitted them to a third party vendor who would produce reports for Medicare. Lisa will wait until August to find out whether the ACO met its goals.

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Joe-FlowerCost is the big factor. Cost is why we can’t have nice things. The overwhelmingly vast pile of money we siphon into health care in the United States every year is the underlying driver of almost every other problem with health care in the United States from lack of access to waste to fragmentation to poor quality. We can’t afford to fix the problems, cover everyone, do real outreach, build IT systems that are interoperable and transparent and doc-friendly — or so it seems, because at least on weak examination every fix seems to add even more cost. And in the old ways of doing things in health care, the way we have been used to doing business, the conclusion of the weak examination has been correct: Despite the tsunami of money, there is never enough to do it right.

Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

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New York has an opportunity to make real improvements to its Medicaid program; but it is leaving out key health care providers which might be best positioned to cut costs and improve value.

The state has undertaken a $6.4 billion dollar initiative, the Delivery System Reform Incentive Payment (DSRIP) program, to reduce avoidable hospital use by 25 percent over the next 5 years. DSRIP is testing ways to do everything from cutting unnecessary emergency room visits to reducing transmission of HIV/AIDS.

This could lead to healthier, more productive lives for New York’s 6 million Medicaid beneficiaries and could generate positive spillover effects for all New Yorkers—if hospitals, physicians, and other providers adopt better ways to manage Medicaid patients, they are likely to use those improvements to assist all their patients.

A team approach, coupled with preventive health care to avoid hospitalization and appropriate follow-up care, is an important part of the strategy. Better coordination between community physicians and the hospital, and better information for patients, can save money and improve health outcomes.

The problem? New York’s DSRIP program is mainly confined to “safety net” providers,  including hospitals, academic medical centers, nursing homes, individual physicians, and others with a high volume of Medicaid or uninsured patients. The state limits the participation of physician groups known as Independent Provider Associations (IPAs) because they are not considered Medicaid providers.

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By JOEL KUPERSMITH, MD

As shown by breaches of personal information on innumerable individuals over the years, our approach to IT security falls short. Recent intrusions at Sony Pictures Entertainment and Anthem Health (80 million individuals) against a backdrop of substantial losses of personal health (PHI) and other IT information previously again brought this deficiency again to public attention. According to one estimate, almost 1 billion records were stolen via 1500 breaches in 2014, a 78% increase from the previous year and a clear indication of an increasing problem. Among personal information, health records are particular targets, bringing in $20 per record versus $1-$2 for a credit card and surveys consistently show considerable public concern about the privacy of PHI.

In a recent commentary, David Brailer proposed that raised security standards for health information be one of four principles underlying new privacy legislation. I strongly agree and would add a specific step to apply this principle – privacy accreditation for health data custodians.

Whether the information is stored for care, insurance or research, the public lacks understanding of the complexity of their stored PHI and the large number of individuals with access to or custodial responsibility for it. There is thus a wide gap and power differential between data providers and those who hold enormous amounts of sensitive health data. This circumstance creates a need for an empowered intermediary to act on the public’s behalf, i.e. an accreditation body.

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Ashish JhaA few months ago, the Centers for Medicare and Medicaid Services (CMS) put out its latest year of data on the Hospital Readmissions Reduction Program (HRRP). As a quick refresher – HRRP is the program within the Affordable Care Act (ACA) that penalizes hospitals for higher than expected readmission rates. We are now three years into the program and I thought a quick summary of where we are might be in order.

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.

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Tom GuillaniThere is no doubt that the topic of patient engagement has taken center stage in healthcare. It was the hot topic at HIMSS 2015 where a major national study was unveiled, Three Perspectives of Patient Engagement. And that was just one of the many sessions, events, and booths focused on patient engagement at the event.

Thanks to Meaningful Use, a lot of the focus on patient engagement has been around patient portals. It makes sense since practices have to meet specific thresholds in both MU2 and MU3 for portal use. They certainly play a key role in providing patients with access to medical records, test results, and even tools like online scheduling and billpay. The benefits have not gone unnoticed by providers. Over 80% of doctors believe a patient portal helps with patient satisfaction and 71% believe it helps with patient/physicians communication. The benefits haven’t gone unnoticed by patients either. Two-thirds of patients say they would be more loyal to physicians who provides a portal through an EHR.

Despite the undeniable value of portals, they are just one component of true patient engagement. This was clear in the presentation about the new national study released at HIMSS. According to the presentation, the biggest problem in creating patient engagement isn’t providing access to health information. The problem is shifting the attitudes and expectations of both clinicians and patients.

Resolving this problem requires a major culture change in healthcare. Despite the fact that patients and providers say they want improved access, communication, and outcomes and that patient engagement may hold the key, change is slow.

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Michelle Noteboom: Give me a bit of background on your hospital.

Ron Rutherford: Jordan Hospital is a 100-plus-year-old, a 155-bed community hospital that actually was acquired and became a part of the Beth Israel Deaconess Health System in January of 2014, so just over a year ago. We’re a full-service community hospital serving 200,000 or so residents in eleven communities. There are few services we don’t provide but mostly we offer all of them.

MN: You recently implemented the Voalte smartphone solution. What led you to seek a new communication platform?

RR: We recognized the need for our clinical users to be able to communicate in the most efficient way possible and we were aware of some technology tools that could make that happen. We were also conscious that the communication had to be secure