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 “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”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
We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.
But suppose this correspondent alerted you to:
1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.
If you think that sounds like typical vendor-driven telephonic disease management, you’d be right. You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses. When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.
Continue reading “Why Disease Management Won’t Be Going Away Any Time Soon”
Filed Under: The Business of Health Care
Tagged: CMS, Commonwealth Fund, Disease Management, Group Health, Insurers, Jaan Sidorov, Outcomes, Patients, PCMH, prevention, vendor-driven disease management, Vendors
Apr 2, 2013
Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over “population health.”
This correspondent says the article is what is muddled and that the readers of JAMA deserve better.
According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing “population health” for an entire geography.
Between the here of “improving chronic care” and the there of “population health,” Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term “population health” in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.
Continue reading “Accountable Care Organizations Can Change Everything, But Only If We Get the Definition Right”
Filed Under: Hospitals, OP-ED, THCB, The Business of Health Care
Tagged: ACOs, Affordable Care Act, Care Continuum Alliance, Douglas Noble, Jaan Sidorov, JAMA, Lawrence Casalino, Outcomes, Patient-centered care, Population Health, Quality
Mar 20, 2013
I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.
Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?
And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as ”apprentices” and “journeymen” before becoming ”craftsmen.”
All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.
Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.
Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.
Continue reading “The Rise of the Non-Physician Expert”
Filed Under: OP-ED, THCB, The Insider's Guide To Health Care
Tagged: competency, degrees, Doctor of Medicine, Education, Jaan Sidorov, med school
Feb 14, 2013
On occasion, your correspondent fights the northeast’s dreary weekend winter evenings with a dram of spirituous liquor like Macallan 12. Unlocked with a small splash of water and a single ice cube, a generous ounce of that pungent cinnamon leathery elixir turns the cold into cozy.
So naturally, your correspondent relies on spouse to help keep a therapeutic stock available. Both yours truly and spouse run errands and it shouldn’t be too hard for either to be proactive by periodically checking supplies, buying some Macallan when necessary and avoiding the unhappiness of a dispirited and cold author.
Unfortunately, spouse doesn’t always see it that way.
Welcome to the complicated world of behavioral economics. It tells us that it’s difficult for persons to expend effort today to reduce the tomorrow’s risk of an unlikely event. It’s why many persons chose to not take or pay for medications today to reduce the distant likelihood of disability or early death. There’s more on the topic here.
This also explains why persons don’t do a good job getting a flu shot for themselves or their loved ones. Check out this interesting information from athenahealth. According to their pooled electronic health record (EHR) data, 2.5% of children without a flu shot came down with the flu, versus only 0.9% of those who got the shot. While getting a shot reduced the relative risk of coming down with the disease by approximately two thirds, the vast majority of kids who went without immunization (97.5%) did OK. Data from the CDC in adults reflects the same kind of numbers: 80% of persons in the U.S. do not come down with the flu in the course of the year.
How can the population health and care management community leverage behavioral economics to increase immunization rates?
Continue reading “Behavioral Economics and Influenza Immunization”
Filed Under: Health Plans
Tagged: behavioral economics, Immunization Rates, Incentives, Influenza, Jaan Sidorov, Macallan approach, Population Health Management, Preventive medicine, risk prediction, Uncle Joe Fallacy
Feb 10, 2013
When persons are admitted to a hospital, insurers’ payment rates are based on the diagnosis, not the number of days in the hospital (known as a “length of stay”). As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible. My physician colleagues used to refer to this as “treat, then street.”
Unfortunately, discharging patients too soon can result in readmissions. That’s why I have agreed with others that diagnosis-based payment systems and a policy of “no pay” for readmissions were working at cross purposes. Unified bundled payment approaches like this seem to be a good start.
But that’s all theoretical. What’s the science have to say?
Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine.
The authors used the U.S. Veterans Administration (VA) Hospital’s “Patient Treatment Files” to examine length of stay versus readmissions in 129 VA hospitals. The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).
As length of stay went down, readmissions should have gone up, right?
Continue reading “Building Smarter Hospitals: The Widely Misunderstood Relationship Between Discharging Patients Too Early and the Likelihood of a 30 Day Readmission”
Filed Under: Hospitals
Tagged: hospital readmissions, Jaan Sidorov, length of stay, Peter Kaboli, premature discharge, Readmissions, then street, treat
Dec 19, 2012
I really like Twitter. Its scrolling 140-character tableau of news nuggets fit perfectly on my hand held device, lap top and home personal computer. It’s easy to glance at between tasks and the advertising is blessedly minimal. I control the content by following and unfollowing other Twitter accounts with a simple click or a touch.
But why, physician-skeptics may ask, is Twitter any better than traditional web browsing, email, list-servs and handheld apps? I thought about that and am pleased to offer my Top Twelve reasons why every doc should include Twitter in their informatics medical bag.
1. Lit Headlines: The major medical journals use Twitter to efficiently describe their latest content with links.
2. Fame: Traditional print authors are publishing more and more about less and less. Getting peers to follow your original and insightful tweets is the new route to attaining status as an expert. I have more than 500 daily followers vs. how many actually read the average peer-reviewed article?
3. News Junkies: Some of your like-minded peers are freely aggregating and retweeting relevant headlines with links for your perusing efficiency. They can be indefatigable.
4. Kool-Aid Immunity: Did you know your Chief, Chair, VP, lead administrator or Dean wants to control all your communication? Twitter is an easy way to step out of the information bubble and monitor contrary news about that EHR, medical device, performance standards, your institution’s business partners, the competition and more.
5. Efficiency: Twitter trains you to be both brainy and brief. If you can’t fit it into 140 characters or less, you’re wasting your readers’ time.
Continue reading “The Doctor Will Tweet You Now”
Filed Under: THCB
Tagged: Jaan Sidorov, Physicians, Social Media, Twitter
Dec 6, 2012
Hey there Accountable Care Organization executive.
You’re probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal. That’s because you’ve been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital’s lobby.
Well, after you’ve read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.
The article’s title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.
How the study was done:
Kaiser Permanente Colorado added “MyHealthManager” (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once. Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years.
Continue reading “Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates”
Filed Under: Commentology, THCB
Tagged: ACOs, EHR, Jaan Sidorov, Kaiser Permanente Colorado, MyHealthManager, patient portal
Nov 21, 2012
It was just a matter of time until this would happen.
Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will “deny payment” for medical services that are documented in an electronic health record (EHR) using “cloned documentation.”
The topic was covered more than 2 years ago. “Cloned documentation” is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment. Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not “meaningful use” but wasteful abuse.
In addition to congratulating the Times for their crack cutting-edge reporting, here is a prediction…
1. The mere threat of payment denials and the possibility of sanctions will prompt health administrators everywhere to announce at medical staff meetings that “cloned” notes are verboten.
2. Until the “templated note” functionality is deleted in future EHR software updates, physicians will respond to this latest edict from their administrators in the traditional manner: they’ll ignore it.
Continue reading “Outlawing Templated Notes in the Electronic Health Record”
Filed Under: THCB
Tagged: CMS, EHR, Jaan Sidorov, National Government Services, New York Times, OIG Report, smart templates
Oct 16, 2012
While the Governor’s Mansion in Pennsylvania is currently under the control of the Republicans. I know the state’s Insurance Department is relatively apolitical. That’s why this September statement by Pennsylvania Commissioner Consedine before the U.S. House Ways and Means’ Subcommittee on Health is quite telling.
In it, Mr. Consedine describes how the Keystone state is encountering difficulties implementing an health insurance exchange. As readers will recall, exchanges are a key feature of the Affordable Care Act, because they’ll provide an online market that will enable individuals to obtain coverage.
According to Mr Consedine, CMS is failing to support a good law with the many regulatory details that turn a vague idea into a functioning reality. These failings include:
1. “Interim,” not “final” rules on eligibility, tax credit calculations, cost sharing and the role of brokers
2. Little formal guidance on the determination of the essential health benefit.
3. Delays in issuance of regulations on how states and Uncle Sam will split or mutually indemnify the myriad costs of the exchange and the Federal Data Hub.
Continue reading “Will the Rollout Of the Exchanges Be Delayed?”
Filed Under: Health Plans
Tagged: Affordable Care Act, CMS, Consumer Protection, essential health benefit, Health insurance, Health Insurance Exchanges, HHS, HIT, Jaan Sidorov, Michael Consedine
Sep 25, 2012