There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.
In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:
Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients (1).” Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967.
In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.
Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011.
They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement (3).”
And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.
Continue reading “Primary Care 2.0: A Vision for a Transformative Solution”
Filed Under: Physicians, THCB, The Business of Health Care
Tagged: American Academy of Pediatrics, NCQA, PCMH, primary care, Retail Clinics
Mar 3, 2014
I wish I had a better story to tell you about why I am typing this with one hand (and some help from Dragon Dictate).
A shark attack would be interesting. An assassination attempt would be intriguing. Skydiving mishaps always make for good copy. An out-of-control quad copter that turns on its master would be entertaining (and would come complete with a grim, potentially viral, video).
No, the reason I am now one-handed is a little more prosaic than those scenarios.
I had finished my last shoot after a long reporting trip to Japan and the Philippines and was stacking the Pelican cases brimming with TV gear onto my cart. As I tried to bungee cord them into some semblance of security for movement, one of the cases toppled onto my left forearm. Ouch! It hurt, but I wasn’t all “911” about it. It was painful and swollen but I figured it would be okay without any medical intervention. Maybe a little bit of denial?
The next day, February 13, things seemed status quo. It was sore and swollen but seemingly no worse. Then, that night, things got worse. Both the pain and swelling increased.
So on the morning of February 14, I asked the hotel for a referral to a doctor and went to see him right away. While my concern was already growing, the look on his face when he saw my forearm got me a little more nervous.
The doctor told me he suspected that I might be having an Acute Compartment Syndrome. I had to Wiki it, but in essence it is an increase in pressure inside an enclosed space in the body. This can block blood flow causing a whole host of serious, life-threatening consequences.
He had me admitted to the hospital. Over the next few hours, I endured probably the longest, most painful experience I could ever imagine. My forearm developed some dusky discoloration, but more alarming was the numbness. I could not feel my forearm!
The doctor recommended an emergency fasciotomy to relieve the pressure. This is a gruesome enough procedure on its own, but the he was clear that the problem was progressing rapidly and there was a clear and present threat to my limb.
Continue reading “Just a Flesh Wound”
Filed Under: THCB
Tagged: Acute Compartment Syndrome, Emergency amputation, Fasciotomy, Miles O'Brien, Wellness
Mar 3, 2014
The dude writes:
“I’m looking into a new EMR for our just incorporated small group practice. I’m diligently doing my Google research. Frankly, I’m not at all impressed by the quality of the information I’m finding out there. Both the professional and the customer reviews I’m finding leave a lot to be desired.
The tone of many of the reviews I’m reading makes me wonder how reliable and objective they are. A suspicious number of customer reviews are blandly positive, as if they were written by a corporate drone in a cubicle somewhere. They’re full of industry buzzwords and praise: “Met all of my expectations ” and “is everything I could ask for in an EMR system.”
I’ve read enough patient and restaurant reviews online to know that reviews generally fall into two categories: angry customer and worshipful. The former almost always outnumber the latter by a margin of 4:1 But not here. Here its the other way around! The tone of the professional reviews also seems strangely subdued.
At least one popular review site (Software Advice) appears to take a direct commission from EMR vendors for each referral. They say this doesn’t impact them and that they’re objective, but this clearly biases them in my mind. What resources do people recommend?
And why doesn’t THCB run user reviews???
Filed Under: THCB
Tagged: Comparison shopping, EHRs, EMRs, Reviews, Software Advice, Tech Journalism, THCBist
Mar 3, 2014
Narrow Networks: Boon or Bane?
Bigger Hospitals Mean Bigger Hospitals with Higher Prices. Not Better Care.
Metrics: Surprisingly, people who were uninsured last year remain undecided about the ACA,
Clinic: A cautionary note about the risks of blood pressure treatment in the elderly.
In Defense of corporate wellness programs.
Do workplace wellness programs make business sense?
Doctors without (state) borders.
Amazon.com as a delivery model for population health.
How Mayo Clinic is using iPads to empower patients.
Can Oscar succeed in making health insurance fun? Maybe not just yet ….
That vitamin over there could kill you.
How Reliable are EMR reviews, anyway???
Transparency a go go …
CVS Caremark is entering CommonWell.
Seven reasons your doctor is still using technology that sucks.
Are payors changing what they’re are paying for medical billing codes to adjust for supply and demand?
What you need to know about patient matching and your privacy and what you can do about it.
Filed Under: THCB
Mar 2, 2014
Two announced hospital deals – Fosun Pharma’s (复星医药) announced acquisition of Chindex International, Ltd., and a partnership between Evergrande Real Estate Group (恆大集團) and Harvard’s Brigham and Women’s Hospital– have generated much discussion in niche investors and analyst communities about how much, or how little, investors should be excited about the possibility that China’s healthcare service sector is open to investment.
In point of fact, these two deals are not cause for optimism. Rather, they are the story of the inability of healthcare services in China to make a profit writ large.
With few very minor exceptions, and the reputations of Chindex and Harvard notwithstanding, no single institution in China has yet figured out how to make hospitals, and more generally, healthcare services, profitable in China in the long term; not the Chinese government, not private Chinese firms, not the semi-foreign companies from Taiwan-Macao-Hong-Kong, and certainly not truly foreign firms from other Western countries.
Moreover, it is very unlikely that a sustainable profit model is a real possibility in the short to mid-term. China’s mix of government policies and ministry regulations disadvantage private health service institutions in the marketplace through discriminatory tax treatment relative to public hospitals, market entry limitations that force private hospitals into underdeveloped population zones and stall expansion projects, as well as various other acts that make it difficult for private health providers to compete with public hospitals in the recruitment of capital and medical staff.
Until last week at least, despite these challenges, the United States could claim one successful and prominent entry in China’s private healthcare arena – the United Family Care family of hospitals and clinics, run by Chindex International, Inc. Chindex opened Beijing United Family Hospital in 1994, and since then opened up several more clinic branches across China, including the United Hospital in Shanghai .
However, when Shanghai Fosun Pharmaceautical Group Co Ltd (from here on out “Fosun Pharma”) announced that it was partnering with equity house TPG Capital to acquire Chindex in a deal valued at $369 million, the United States lost this single claim to success in China’s healthcare services market.
The deal, when finalized, will give Fosun Pharma majority ownership of Chindex, result in Chindex becoming a private company, and will turn the beacon of American success in the Chinese healthcare industry into a subsidiary of a Chinese conglomerate.
Continue reading “Why Everything You Know about Health Care in China Is Wrong”
Filed Under: THCB, The Business of Health Care
Tagged: Chindex International, Fosun Pharma
Mar 2, 2014
Since mid-December, we’ve brought you the latest data on public opinion of the Affordable Care Act (ACA) from the RAND Health Reform Opinion Study (RHROS), a new way to measure public opinion of health reform. The RHROS allows us to observe true changes in opinion by surveying the same people over time.
The trend of overall stability masking churn in individual opinion that we discussed last week has continued with our latest data. This week, however, we delve deeper to look at differences in opinion between two groups: those who had insurance in 2013 and those who did not.
Understanding how the ACA impacts these groups differently is particularly important. While the ACA is currently changing the landscape of health insurance, its impact should be especially pronounced for Americans who lacked access to insurance through their employer or government programs in 2013.
The following graph illustrates the opinions over time of all individuals who had insurance, regardless of the source.
This includes those who had coverage through their employer, purchased it on the private market, or received it through a variety of government programs, such as Medicare and Medicaid.
This group represents about 85 percent of the overall sample.
This graph shows opinion of the ACA among those who were uninsured in 2013:
At first glance, what’s striking about these two graphs is how similar they are—more on that in a moment—but there are actually some very important differences.
Continue reading “Metrics: Surprisingly, People Who Were Uninsured Last Year Remain Undecided About the ACA”
Filed Under: THCB
Tagged: health reform, Katherine Grace Carman, Open Enrollment, RAND Health Reform Opinion Study (RHROS), The ACA, the uninsured
Mar 1, 2014
When it comes to high blood pressure treatment in the elderly, the plot continues to thicken.
Last December, a minor controversy erupted when the JNC hypertension guidelines proposed a higher blood pressure (BP) treatment target (150/90) for adults aged 60+.
And now this month, a study in JAMA Internal Medicine reports that over 3 years, among a cohort of 4961 community-dwelling Medicare patients aged 70+ and diagnosed with hypertension, those on blood pressure medication had more serious falls.
Serious falls as in: emergency room visits or hospitalizations for fall-related fracture, brain injury, or dislocation of the hip, knee, shoulder, or jaw. In other words, we talking about real injuries and real patient suffering. (As well as real healthcare utilization, for those who care about such things.)
How many more serious falls are we talking? The study cohort was divided into three groups: no antihypertensive medication (14.1%), moderate intensity treatment (54.6%), and high-intensity treatment (31.3%).
Over the three year follow-up period, a serious fall injury happened to 7.5% of those in the no-antihypertensive group, 9.8% of the moderate-intensity group, and 8.2% of the high-intensity group. In a propensity-matched subcohort, serious falls happened to 7.1% of the no-treatment group, 8.6% of the moderate-intensity group, and 8.5% of the high-intensity group. (Propensity-matching is a technique meant to adjust for confounders – such as overall illness burden — between the three groups.)
The methodologists in the audience should certainly read the paper in detail and go find things to pick apart. For the rest of us, what are the practical take-aways?
Continue reading “Clinic: A Cautionary Note About the Risks of Blood Pressure Treatment in the Elderly”
Filed Under: THCB
Tagged: Blood Pressure, Geriatrics, Leslie Kernisan, Telemonitoring, Wellness
Feb 28, 2014
There’s that line about art, “good artists copy, great artists steal.” There’s some debate about if Picasso said it first, but most of us geeks know it from Steve Jobs.
Often, I see things from companies and industries outside of healthcare —processes, products, best practices —which inspire me. I like these little inspirations because they often aren’t rocket science, but nonetheless fuel some creative thoughts about their applicability in healthcare.
The other night, around 9:00 PM on a holiday Monday, I ordered some obscure aviation stuff from Amazon. I needed a new headset, a leg-mounted chart holder, a paper calculating tool called an E6B computer and a portable canister of oxygen.
I have Amazon Prime, their subscription service which provides expedited 2 day shipping, so I expected to see my stuff on Wednesday afternoon. I was blown away when there was an Amazon box outside my door by 9:00 AM the next morning, Tuesday.
A box showed up early, big deal, right?
Here’s what I think happened and why I’m so impressed. I had been browsing for some aviation stuff for a few days. Amazon clearly knows and tracks my window shopping. It’s how they suggest items when you come back to the site.
I believe they preemptively moved some of those obscure aviation items to the closest distribution center in anticipation of my purchase. In fact, Amazon was awarded a patent for exactly that process last week.
By predicting my purchasing behavior, Amazon was able to beat my expectations for delivery – a known threat to their model is the instant gratification of local retail – and get my package to me in 12 hours.
We’ve got a lot of data in healthcare. That’s to the lagging but persistent implementation of electronic medical records, doctors and health systems are beginning to apply some big data science to their patient populations. For instance, any credible EMR can tell a physician how many of her patients have asthma.
More advanced systems, including bolt on solutions can look at disease panels and cross sample against last visit date. Mr. Smith, we see it’s been a year since your last visit, how’s your arthritis? Can we schedule you and appointment with Dr. Jones?
Continue reading “Amazon.com as a Delivery Model for Population Health”
Filed Under: Tech, THCB
Tagged: Amazon.com, Innovation, Nick Dawson, Population Health
Feb 27, 2014
Throughout the world, companies are embracing mobile devices to set customer expectations, enlist them in satisfying their own needs, and get workers to adhere to best practices. An effort under way at the Mayo Clinic shows how such technology can be used to improve outcomes and lower costs in health care.
Defining the care a patient can expect to receive and what the road to recovery will look like is crucial. When care expectations are not well defined or communicated, the process of care may drift, leading to unwarranted variation, reduced predictability, longer hospital stays, higher costs, poorer outcomes, and patient and provider dissatisfaction.
With all this in mind, a group at the Mayo Clinic led by the four of us developed and implemented a standardized practice model over a three-year period (2010-2012) that significantly reduced variation and improved predictability of care in adult cardiac surgery.
One of the developments that germinated in that effort was the interactive Mayo myCare program, which uses an iPad to provide patients with detailed descriptions of their treatment plans and clinical milestones, educational materials, and a daily “To Do” list, and to report their progress and identify problems to their providers.
Continue reading “How Mayo Clinic Is Using iPads to Empower Patients”
Filed Under: Tech, THCB
Tagged: cardiology, Costs, David Cook, iPad, Jeffrey Thompson, Joseph Dearani, Mayo Clinic, myCare, patient empowerment, Sharon Prinsen, Tech, Value
Feb 26, 2014
Some health plans sold through the Affordable Care Act’s (ACA) health insurance marketplaces use “narrow networks” of providers: that is, they limit the doctors and hospitals their customers can use.
Go to Doctor A or Hospital A and the plan will pay all or most of the bill. Go to Doctor B or Hospital B, and you may have to pay all or most of the bill yourself.
The narrow network strategy emerged long before the ACA, during the managed care era in the 1990s, and insurance companies and large, self-insured employers have used narrow networks ever since to control health care costs.
In fact, for the first time, the ACA creates new consumer protections requiring that insurers provide a minimum level of access to local providers. A number of states have exceeded these federal standards using their discretion under the new law.
Nevertheless, some consumer advocates and ACA critics still find narrow networks objectionable. Narrow networks mean that some newly insured people are no longer covered for visits to previous providers, or, if they didn’t have a doctor before, are limited in their new choices. Not infrequently, narrow networks exclude the most expensive doctors and hospitals in a community, including some specialists and academic health centers.
More expensive doctors and hospitals are not necessarily better, but for patients with a rare or complex health problem, such restrictions can be problematic.
Welcome to the world of competition in health care, because that is what narrow networks are about. Narrow networks are used by competing plans to control health care costs, and perhaps improve quality as well. In fact, if you don’t like narrow networks, you’re saying, in effect, that you don’t like competitive solutions—as least under current market conditions—to our health system’s problems.
Continue reading “Reflecting on Health Reform–Narrow Networks: Boon or Bane?”
Filed Under: OP-ED, THCB
Tagged: Commonwealth Fund, Competition, Costs, David Blumenthal, Health Plans, narrow networks, The ACA
Feb 25, 2014