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
It was bound to happen.
By “it,” I mean that the small group of speciality hospitals (usually orthopedic or cardiology-focused) across that country that are owned by doctors were going to have their “See! We Told ‘ya so!” moment.
Doctor-owned hospitals: How many are there? Two hundred and thirty-eight of them in the whole country (out of more than five thousand)–somewhere between four and five percent of the total in the U.S. (numbers courtesy TA Henry from this excellent piece).
What are the issues?
- ObamaCare effectively bans doctors from owning hospitals in the U.S.
- Those already in existence are grandfathered in under the law.
- We know that doctor-owned hospitals have higher average costs–hence the rationale for banning them under a law with the intent of “bending the cost curve.”
Cue the iron-o-meter:
In the most recent Medicare data (December 2012 report on “value-based purchasing“), doctor-owned hospitals did well in terms of achieving quality milestones.
Really well. Physician-owned hospitals took nine out of the top ten spots in the country. And in spite of their low relative number, forty-eight out of the top one hundred.
Continue reading “Doctors and the Means of Production”
Filed Under: Hospitals, Physicians, THCB
Tagged: Affordable Care Act, doctor-owned hospitals, Hospitals, John Schumann, Physicians, the business of healthcare
May 7, 2013
Someone has been listening to me. Or rather, to me and a growing number of voices that are questioning the requirements for admission to medical school. I have argued in a past blog that you won’t get more good primary care doctors, who practice a lot of humanities in addition to the science, if the only people you admit to medical school are scientists. Two medical schools and the American Association of Medical Colleges are beginning to agree.
Pauline Chen gives a good overview of what’s happening in this area here. Essentially, Boston University and the medical school at Mt. Sinai have made pretty radical efforts to apply either more than the traditional evaluation points to their admissions process, or different ones altogether. Mt. Sinai, in particular, has an extraordinary an early-acceptance program for college sophomores and juniors in which they can get into medical school without the MCATs, and without a few of the standard pre-med science and math requirements. In return, the accepted students have to continue to major in an humanities-related field and maintain an adequate GPA. They also have to undergo intensive science enrichment courses prior to matriculation. BU hasn’t gone quite that far, but they have included many more “holistic” data points into their admissions decisions, a process that is extremely labor intensive for the schools’ admissions staff.
Both schools have great ideas that are showing some promising results. I see a couple potential problems:
1. Mt. Sinai seems to be sort of cramming in all the old science requirements in off-hours, allowing students to pursue wider studies in college. I would rather see a larger decrease in the science and math requirements. Basic chemistry and biology are probably necessary, but no one has ever explained to me why you need physics. Or calculus. You don’t need most of this stuff in medical school. All you need in medical school is the ability to put your head down and push through the memorization. You don’t need math, you just need patience. The thing is, the only way to get rid of the math and science is to get rid of the MCAT, because believe you me you can’t get through that behemoth with an english major. Then, even if you do that, you eventually run into Step 1, the first of the three-part exam you take in medical school to pass medical school. The Mt Sinai kids might need more “enrichment” courses to get through that. If those hoops are eliminated, you might find some great doctors underneath those mountainous requirements.
Continue reading “I Was Told There Would Be No Math”
Filed Under: Physicians, THCB
Tagged: AAMC, Boston University, Medical Education, Medical School, Mt. Sinai School of Medicine, Physicians, Shirie Leng
May 5, 2013
What is the path forward for physicians who want to remain in private practice, outside the constraints of health system employment? How will the environment change and what new demands will that place on practices and physicians? What follows are the observations of one industry-watcher who has worked on all sides of health care, but who now spends most his time focused on the interests of those who pay for it. No crystal ball, but several trends are clear.
There are now concrete signs that health care’s purchasers are exhausted and seeking new solutions, that a competitive marketplace is emerging and getting increasing traction. As they abandon ineffective approaches, the paradigm that has dominated the industry for the past 50 years will be upended. The financial pressure felt by buyers will transfer to the supply side health industry that has come to take ever more money for granted.
For decades, fee-for-service payment, inclusive health plan networks, and a lack of quality, safety and cost transparency have been enforced by health industry influence over policy, effectively neutralizing the power of market forces.
Without market pressure, physicians have felt little need to understand their own performance relative to that of their peers. The variation of physician practice patterns within specialties has been high, with some physicians’ “optimizing their revenue opportunities” by veering wildly away from evidence-based practice. Even so, until recently in this dysfunctional environment, it has been nearly impossible to identify high and low performers.
Continue reading “How Physician Practices Can Prepare for a Health Care Marketplace”
Filed Under: Physicians, THCB, The Business of Health Care
Tagged: ACOs, Brian Klepper, Fee-for-service, Physicians, practice management
Apr 24, 2013
I am affiliated with the institution where Dzhokhar Tsarnaev is currently hospitalized. I am friends with people who have treated him. I’m trying to stay away from those people; I would be unable to help asking them about him. They might be unable to help talking about him. There has been a flurry of emails and red-letter warnings cautioning people here not to talk about Mr. Tsarnaev or look him up on the EMR (Electronic Medical Record) system. Despite this there have been leaks of information and photos from various sources. It is virtually impossible to keep people from asking about him and talking about him. Curiosity is human nature. When human nature comes up against morals and laws, human nature will win a good percentage of the time. The question is: given what he has done, does this 19-year-old still have his right to privacy?
The answer, of course, is yes. The American Medical Association includes patient confidentiality in it’s ethical guidelines:
“…the purpose of a physicians ethical duty to maintain patient confidentiality is to allow the patient to feel free to make a full and frank disclosure of information…with the knowledge that the physician will protect the confidential nature of the information disclosed.”
Threre are legal guidelines as well, most notably with the Health Insurance Portability and Accountability Act, or HIPAA. This law was originally passed in 1996 to improve the efficiency and effectiveness of the health care system, allow people to switch jobs without losing their health insurance, and impose some rules on electronic medical information. Congress incorporated into HIPAA provisions that mandate the adoption of the Federal privacy protections for health information. The “simplified” administrative document for the privacy and security portions of HIPAA is 80 pages long. Basically your health information cannot be shared with ANYONE. Of course, there are exceptions to HIPAA. Continue reading ““Did You Take Care of Tsarnaev?””
Filed Under: Physicians
Tagged: BIDMC, Boston bombing, EHR, Ethics, HIPAA, Patient privacy, Shirie Leng
Apr 23, 2013
The Passenger Pigeon. The Dodo bird. The primary care clinic nurse. All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.
Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs. “There are no ‘nurses’” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”
Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms. True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.
This columnist looked for medical literature on the topic. He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape. If he’s wrong, he wants to hear from his readers.
If true, what are the implications?
Continue reading “The Extinction of the Primary Care Clinic Nurse”
Filed Under: Physicians, THCB
Tagged: coordinated care, Jaan Sidorov, Nurses, Patient-centered care, primary care
Apr 22, 2013
Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.
Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.
The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.
A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.
This has medical educators very worried that we will have to do more with much less (disclosure: I am one).
Continue reading “Will Your Health Insurer Pay to Train Your Doctor?”
Filed Under: Physicians, THCB, The Business of Health Care
Tagged: 2014 budget proposal, graduate medical education, Hospitals, Insurers, John Schumann, Kenneth Shine, Medical Loss Ratio, Medicare, Medicare spending, Physicians, Residency, United Healthcare
Apr 16, 2013
Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.
This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.
To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.
While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.
Continue reading “The Global Cardiovascular Risk Score: A New Performance Measure for Prevention”
Filed Under: Hospitals, Physicians
Tagged: Archimedes, David Eddy, GCVR, Global Cardiovascular Risk Score, NCQA, prevention, public health, RWJF
Apr 12, 2013
At a time when one in three Americans report difficulty paying medical bills, up to $750 billion is being spent on care that does not help patients become healthier. Although physicians are routinely required to manage expensive resources, traditional medical training offers few opportunities to learn how to deliver the highest quality care at the lowest possible cost. While the gap is glaring the problem is not new.
In 1975, the department of medicine at Charlotte Memorial Hospital initiated a system to monitor medical costs generated by house officers. In the Journal of Medical Education leaders of the Charlotte initiative described how simply being aware of how clinical decisions impact the costs of care could decrease inpatient length of stay by 21%. Over the last four decades there have been dozens of similar efforts to educate medical students and residents about opportunities to improve the value of care. Some interventions were simple like the one in Charlotte, and simply revealed the cost of routine tests to their trainees. Others provided more sophisticated didactics, interrogated medical records to give trainee-specific feedback on utilization, or creatively leveraged the hospital computer order-entry systems.
Continue reading “Teaching Value: Medical Educators Need to Take Charge and Help Deflate Medical Bills”
Filed Under: Physicians, THCB
Tagged: ABIM Foundation, Choosing Wisely, Christopher Moriates, Costs, FutureMed, Medical Education, Neel Shah, Teaching Value and Choosing Wisely Competition, Vineet Arora
Apr 7, 2013
Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.
This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.
I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.
So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.
But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.
Continue reading “Doctors: We Can’t Leave It to Business to Educate Us”
Filed Under: Physicians, THCB
Tagged: Big pharma, clinicians, digital health, entrepreneurship, Innovation, Journal Watch, Leslie Kernisan, Physicians, the business of healthcare
Apr 5, 2013