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Ashish Jha

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement.  A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse.  Yet, in the last decade, we have seen a sea change.

We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.  But the unease with quality measurement has not gone away and here’s why.  If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria:  good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.

Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect?  What does make a good doctor?  Unsure, I asked Twitter:

good doctor twitter

Over 200 answers came rolling in.
Continue reading “What Makes a Good Doctor? And Can We Measure It?”

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March 2nd through the 8th were National Patient Safety Awareness Week – I don’t really know what that means either.  We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals.

But back to patient safety and National Patient Safety Awareness Week. In recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety.  Which organization is this?  Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety?

It’s an unlikely one:  The Office of the Inspector General of the Department of Health and Human Services.  Yes, the OIG.  This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.

In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them.  The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good:  to begin to look at issues of patient safety far more broadly.

Taken from one lens, the OIG’s approach makes sense:  the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care.  So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does.

Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.

Continue reading “What the Work of the Inspector General Tells Us about Patient Safety…”

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I was just recently in Guiyang, the capital of the Guizhou province in China and had a chance to visit the Huaxi District People’s Hospital (HDPH), one of the largest “secondary” hospitals in the province.

Like the rest of China, it has been gripped by the construction boom, recently opening a new surgery center and revamped medical facilities.  They had a terrific EHR from a local vendor — probably more sophisticated than a majority of U.S. hospitals.

Despite being in one of the poorest regions of China, the hospital has more money than it knows what to do with (so says its leadership) and is planning further expansion. The source of its wealth?  A growing middle class that wants more healthcare services and has the ability to pay for it.

Background on hospitals in China

There are approximately 2853 counties in China across 33 provinces.  Each county has a county hospital, a government owned facility that serves the people of that community.  When the patient is too complicated to be managed there, he or she is transferred usually to a secondary hospital.  Patients who need an even higher level of care are sent to the regional tertiary care hospital.  The gatekeeping system is weak – one need not start at the county hospital – and in fact, a majority of the inpatients at GPH came there directly.

A few years ago, China launched a major health reform with the goal of getting to universal coverage.  They got close and nearly every citizen now has health insurance that covers at least part of the costs of their care.   The insurance has substantial co-pays and doesn’t cover more expensive drugs and tests.  What does this mean for a hospital like HDPH?  About 40% of their revenues came from insurance.

And, despite being a government hospital, only about 5% of revenues came from the government.  The rest?  From the patients themselves.  This revenue mix is supposedly pretty typical of county and secondary hospitals across the nation. Out of pocket spending remains substantial, despite universal health insurance.  In fact, in absolute dollar terms, patients are paying about as much out of pocket now as they were before social insurance kicked in.

Huaxi District People’s Hospital

Outpatient clinics, where a typical appointment might last 2-3 minutes, are by far the biggest source of admissions to the hospital.  But the hospital also has an ER.  Actually, two: a Medicine ER and a Surgery ER.  The patient gets to choose.  Unsure about which you need? There is an “Enquiry” nurse who can help.  I peppered the one on duty with various clinical scenarios and was impressed with the speed and confidence with which she made decisions.

The flow is simple: you choose your ER, you register, pay the fee in cash, and go inside to wait.

Continue reading “The People’s Hospital”

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The most commonly heard comment in healthcare these days is that we have to move from paying for volume to paying for value.  While it may sound trite, it also turns out to be pretty true.  Right now, most healthcare services are paid for on a fee-for-service basis – with little regard for the quality of that service.  We clearly need to move towards value-based payments (sometimes referred to as pay-for-performance or P4P).

Although a few folks remain skeptical about whether VBP/P4P can work (as though our pay for volume strategy is working out so well), asking whether we should pay for volume versus pay for quality no longer seems like a particularly interesting question.

The far more compelling and difficult question is how best to pay-for-performance? As I have written before, we need bold experiments with new payment models that employ three key principles: putting real money on the table, focusing on outcomes, and keeping the reward system simple (i.e. the better you do, the more you should get).

One such new payment model is the value-based purchasing (VBP) program from CMS, the largest payer of hospital care in America. It’s a modest program but an immensely important one.  It is modeled after the Premier Hospital Quality Incentives Demonstration (HQID), which ran for 6 years and had modest effects on hospital performance on process measures and no effect on patient outcomes.

Despite these disappointing findings, the U.S. Congress, in crafting the Affordable Care Act, modeled VBP closely on HQID.  The incentives in the program are small (currently at 1.25% of total Medicare payments) and still more heavily weighted towards process measures than outcomes.

The key question for VBP is whether it will work – whether patients will be better off because of it.  We don’t know and realistically, we won’t for another year or so.

But what we do know is that two years into the program, certain hospitals seem to be doing well and others, not so much. Yes, the incentives are small and my guess is that any impact will be very modest as well.  But, it’s still worth taking a look at how different types of hospitals are faring under VBP.

So we ran some numbers.

Continue reading “Finding the Value in Value-Based Purchasing”

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In my previous blog, I made the argument that whatever strategy we use to improve care in hospitals will not be implemented and executed well without proper focus by hospital leadership.  So, it is in this context, that we recently published some pretty disappointing findings that are worth reflecting on.

We examined the pay of CEOs across U.S. hospitals and found that some CEOs got paid a lot more than others.  This was not surprising.  CEOs of larger, urban, teaching hospitals get paid a lot more than CEOs of small, rural, non-teaching institutions.  But the disappointment was around quality:  we found no relationship between a hospital’s quality performance and the pay of the CEO.  Holding size, teaching, and other factors constant, what was the pay of CEOs of hospitals with high mortality rates?

About the same as CEOs of hospitals with low mortality rates.  What about other quality measures?  Most of them didn’t really seem to matter, with the exception of patient experience, which correlated nicely with CEO compensation.  It seems that when setting CEO compensation, patient outcomes are not a big part of the discussion.  How could this be, and why does it matter?

How you set incentives for senior managers says a lot about your priorities.  Boards generally set the salary for their CEOs and they clearly reward patient satisfaction scores.  That’s good.  They also seem to reward the things that build hospital reputations: having the latest technology such as a PET scanner or academic status.  But are boards rewarding CEOs based on mortality rates or adherence to basic quality metrics?  Not so much.  Why not?  I’ve spoken to a lot of board chairpersons over the years and the answer is not that they don’t care.  Most boards want to reward quality and believe that they do.

The problem is that most board members lack sufficient expertise on quality metrics and can’t decipher, from the large number of quality metrics, which ones are important (like mortality rates) and which ones are not.  Hamstrung, they focus on satisfaction but also end up rewarding things that feel like proxies for quality, such as having the latest technology.  And here’s the part that’s frustrating – our national efforts on quality measurement and improvement are not helping.  We seem to have done very little to prioritize what’s really important, and shine a light on them.

So what do we do to move forward?  Some states have started requiring that boards undergo training in quality.  Medicare, as a condition of participation, could certainly require that boards (or at least some members thereof) show a degree of expertise with quality.  I like these ideas but worry that training programs would themselves be of variable quality, and for some boards it would become an onerous requirement without achieving real gains in expertise.

Of course, if we really want to help boards be more effective and engage healthcare leaders, the biggest thing that we could do is actually reward hospitals, in a meaningful way, based on quality.  Yes, we have the value-based purchasing program, and it is well-intentioned.  But, as I’ve written before, it has several big problems.  First and foremost:  the incentives are very weak and there is little reason to believe it will have a meaningful impact on patient outcomes.  Second, the measures are diffuse – we have too many of them, some of which matter (mortality) and many which don’t in the absence of the appropriate clinical context (checking the ejection fraction on a heart failure patient).  It’s hard for hospital boards to really get a clear signal on what matters if they aren’t seeing it clearly and consistently from national leaders on quality.

Continue reading “Hospital Exec Pay: If P4P is Good Enough for Doctors, Why Not the CEO?”

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I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.

He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening.  He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs.  After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.

That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath:  he had a large saddle pulmonary embolus.  He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care.  He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality.  Even after discharge, he received two nursing visits at home to ensure he was doing OK.  In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed.  Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.

This is the story we all hope for.  And when I heard it, I have to say that I wasn’t surprised.  There’s something about the BIDMC that’s unusual.  Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted  mortality rates for all three reported conditions:  heart attack, congestive heart failure, and pneumonia.  And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.

If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.

So what’s so special about them?  What do they do that’s different?  I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest.  And in a word, it’s leadership.  BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care.  That commitment translates into real activities that make a big difference.  Let me divert us with a story of what this might actually mean.

A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare.  As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation.  One call is particularly memorable.  Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?

The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better.  When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.

Continue reading “How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals”

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Why readmission penalties are controversial

Penalizing hospitals for high readmission rates has been pretty controversial.  Critics of the program have argued that readmissions have little to do with what happens while the patient is in the hospital and are driven primarily by how sick or how poor the patient is.  Advocates of the readmissions program increasingly acknowledge that while readmissions may not reflect the quality of care that occurred within the hospital, someone should be accountable for what happens to patients after discharge, and hospitals are the logical choice.  While the controversy continues, there is little doubt that the metric is here to stay.  This October, the CMS Hospital Readmissions Reduction Program (HRRP) will increase its penalty on excess readmissions from 1% to 2% of total hospital reimbursement.

So far, CMS has focused on readmissions that occur after patients are discharged with one of three medical conditions—acute myocardial infarction, pneumonia, and congestive heart failure.  The data on the impact of the program are mixed:  while readmission rates appear to be dropping, the penalties seem to be targeted towards hospitals that care for some of the sickest patients (academic medical centers), poorest patients (safety-net hospitals) and for heart failure, some of the best hospitals (those with the lowest mortality rates).  No wonder the program has been controversial.

Why surgery may be different

In 2015, CMS extends the program to focus on surgical conditions, which provides an opportunity to think again about what readmissions measure, and what it might take to reduce preventable ones.  And if you think about it, surgery may be different.  Most patients who are admitted for Acute MI, CHF, and pneumonia are chronically ill and bounce in and out of the hospital, with any one hospitalization likely just an exacerbation of underlying chronic illness (especially true for pneumonia and heart failure).  Not so for surgery—at least not for the major surgeries.

Continue reading “Finally Some Good News on Readmission Rates”

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The Bike Path:

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder.  I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.

As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.

The Emergency Room:

We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.

It started off well enough – a triage nurse saw me walking in holding my arm, in distress.  She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life.  I was then shuttled to registration, where I was asked to repeat all the same information.  It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question.   Initially, the same ones: name, address, phone #, etc.  Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.

I told her I was in excruciating pain and needed help.  A few more questions, she said.  She needed the complete registration.

I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster.  The x-ray technologist avoided eye contact.  It was hard — I was right outside her room.  Finally, I asked a passerby if she could help.  Caught by surprise (I must have sounded human), she stopped.  She looked at me.  She then went into the x-ray suite.  A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful.  He told me the ER was pretty quiet and he would get me in right away.

Continue reading “Average Care at a Typical Hospital on an Ordinary Sunday in August”

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Right now there’s a fierce debate going on for the hearts and minds of health IT. Finally American health care (well, half of it anyway) is using electronic medical records. But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.

Worse, those who promote the impact and importance of EMRs (Farzad MostashariAshish Jha) are being attacked by Ross Koppel, Steve SoumeraiScott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.

This reminds me of the World War One British Army preparing to fight in the mud of Flanders with cavalry charges suited to the Boer War, the French Army in 1939 retreating to their WWI style trenches while the Germans flew over them, and (dare I say it) today’s TSA strip searching grandmothers looking for boxcutters.

Yes, we’re having the wrong fight by focusing on old problems. The EMRs that are producing the studies we’re fighting about are the current equivalent of 1990s EPR implementations. In general they’re hard to use and require lots of money and training to produce halfway decent results. The real improvements from IT came when user-centered tools came to consumers and then to business with Web 2.0 and new devices like the iPhone.

It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.What we’re seeing every day at Health 2.0 is a whole new generation of data-driven applications and devices that are going to make the health care user experience much more like the one my daughter has.

When we get there, the real improvements in both productivity and safety, as well as in quality and even cost, will emerge and we’ll wonder why we ever were having this fight.

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If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
Continue reading “More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology”

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