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Outcomes

Craig GarthwaiteTwo weeks ago, the Kellogg School of Management was privileged to host Joe Doyle, an outstanding economist from MIT.

In a broad research portfolio, Joe has focused on the effects from differing intensity of medical treatments.

This research is shattering some long held beliefs about the relationship between health spending and outcomes.

We think that Joe’s work is not known widely enough outside of the academic community, so we are using our blog to let you know what you have been missing and, in the process, perhaps change the way you think about healthcare spending.

It is well known that the U.S. far outspends other nations on healthcare, yet the outcomes for Americans (in terms of coarse aggregate measures such as life expectancy, infant mortality, and other dimensions) are quite average.

Of course, these outcomes are not the only things that we value in health care.

A lot of our spending is on drugs and medical services that improve our quality of life and won’t show up in these aggregate outcomes. For example, more effective pain management can decrease pain and improve quality of life – often with important economic benefits.

Despite this fact, most health policy analysts have concluded that we can cut back on health spending, without harming quality on any dimension.

This is not a new idea, of course. In a famous 1978 New England Journal article, Alain Enthoven coined the term “flat of the curve medicine” to describe how the U.S. had reached the point of diminishing returns in health spending. And for nearly 30 years the Dartmouth Atlas has documented how health spending dramatically varies across communities without any apparent correlation with outcomes.

The question has always been, what health spending to cut? Garthwaite’s previous work has shown that broad regulations requiring longer hospital stays for new mothers and their babies have provided only limited benefits and that more targeted rules could save money without sacrificing quality.

Beyond some wasteful regulations, we can always point to gross examples of overspending such as the rapid proliferation of proton beam treatments. But beyond those clear examples how can one identify what is waste and what is medically necessary?

In two important papers, Joe Doyle and co-authors ask a more fundamental question – is the often cited broad variation in health spending actually wasteful at all? They find that even in healthcare, there really is no such thing as a free lunch.

His work should be mandatory reading for everyone who believes that broad spending cuts will have no adverse consequences.

For those who lack the time to read these papers, we provide the “Cliff’s Notes” versions.

Continue reading “Is Higher Spending Truly Wasteful?”

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More than 55 percent of the U.S. population now lives in a local area with an accountable care organization (ACO), in which a group of providers is held accountable by a payer for the total cost and quality of care for a defined set of patients. The spread of ACOs, however, by no means ensures their success.

Significant questions remain about whether the goals of the model—better care at lower costs—will be achieved.

There are some signs that the ACO model—by rewarding provider organizations for implementing high quality mechanisms for care delivery that lower overall costs—is driving innovation in the marketplace. For example, the Montefiore ACO in New York City is using special scales in the homes of patients with congestive heart failure to monitor for changes in weight that could indicate trouble.

Walgreens has formed three ACOs and is using its retail pharmacies as low-cost care centers. In addition, the Beth Israel Deaconess Care Organization created a high-touch care management system in which nurse practitioners visit the ACO’s sickest patients at home to reduce the number of hospital readmissions.

Yet, there are also challenges inherent in the adoption and implementation of the ACO model. There have been several wide-ranging proposals on how to enhance accountable care, especially in Medicare, but we believe that developing policies to standardize measurement is an important first step.

First, we need to promote adoption of a core set of effective measures across payers. Current measures, such as screening for high blood pressure, are limited in scope and fail to incorporate important dimensions, including health outcomes meaningful to patients and the total cost of care for those within the ACO. Proposals for more advanced measures have been developed but not yet adopted, in part because of provider concerns about being held accountable for aspects of performance they do not fully control.

These issues could be addressed by operationalizing the concept of “shared accountability” through patient engagement and partnerships, as with local, multistakeholder community health coalitions, and embracing a core set of more challenging and meaningful metrics, such as functional health and total costs per capita.

Continue reading “Measuring What Matters for ACOs”

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People in health care don’t like it when numbers emerge that are uncomfortable.  Take these, issued today by the Massachusetts Health Policy Commission in its latest report on the drivers of the high cost of care in our state.

Variation, particularly when not correlated to quality of outcome, is particularly troublesome for some incumbents.  Academic medical centers often have their answer, but as the HPC explains, it doesn’t hold water:

One oft-cited theory for the cause of this variation is that certain types of hospitals, such as those that teach physician residents and fellows, must incur additional expenses to support their mission. However, the difference in median expenses per discharge between teaching hospitals and all hospitals ($1,030) was less than the difference between individual teaching hospitals ($3,107 between the 75th percentile and 25th percentile teaching hospitals). Moreover, there were a number of teaching hospitals that incurred fewer expenses per discharge than the statewide all-hospital median of approximately $9,000 per discharge.

So perhaps the high cost ones will now revert to the usual squawking: “This isn’t fair. The data are wrong.  Our patients are sicker.”

Except here, the data are the best that could be available–all the claims for all the hospitals and all the payers in the state–even adjusted for wages.  And the acuity of patients across the spectrum of academic medical centers does not vary widely–but, just in case, the numbers are case-mix adjusted.

Continue reading “The Data Are Wrong. Our Patients Are Sicker!!!”

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The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.

But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.

Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?

Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.

But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.

In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.

Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).

On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.

Continue reading “In Medicine, More May Not Be Better”

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Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient’s clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

Continue reading “An “F” for Quality”

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Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed. Continue reading “A Time of Change at the American Board of Internal Medicine”

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If you have ever tried to choose a physician or hospital based on publicly available performance measures, you may have felt overwhelmed and confused by what you found online. The Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group, and the National Committee for Quality Assurance, as well as most states and for-profit companies such as Healthgrades and U.S. News and World Report, all offer various measures, ratings, rankings and report cards. Hospitals are even generating their own measures and posting their performance on their websites, typically without validation of their methodology or data.

The value and validity of these measures varies greatly, though their accuracy is rarely publically reported.  Even when methodologies are transparent, clinicians, insurers, government agencies and others frequently disagree on whether a measure accurately indicates the quality of care. Some companies’ methods are proprietary and, unlike many other publicly available measures, have not been reviewed by the National Quality Forum, a public-private organization that endorses quality measures.

Depending where you look, you often get a different story about the quality of care at a given institution. For example, none of the 17 hospitals listed in U.S. News and World Report’s “Best Hospitals Honor Roll” were identified by the Joint Commission as top performers in its 2010 list of institutions that received a composite score of at least 95 percent on key process measures. In a recent policy paper, Robert Berenson, a fellow at the Urban Institute, Harlan Krumholz, of the Robert Wood Johnson Foundation, and I called for dramatic change in measurement.  (Thanks to The Health Care Blog for highlighting this analysis recently.)

We made several recommendations, including focusing more on measuring outcomes such as mortality and infections rather than processes (e.g. whether patients received the recommended treatment) or structures of care (e.g. whether ICUs are staffed around the clock with critical care specialists). We urged that measures be at the organization level rather than clinician level, to reflect the fact that safety and quality are as much products of care delivery systems as of individual clinicians. We propose investments in the “basic science” of measurement so that we better understand how to design good measures. You can read these and other recommendations in the analysis.

Continue reading “A SEC for Health Care?”

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The unfortunate reality is that there is no body of expertise with responsibility for addressing the science of performance measurement. The National Quality Forum (NQF) comes closest, and while it addresses some scientific issues when deciding whether to endorse a proposed measure, NQF is not mandated to explore broader issues to advance the science of measure development, nor does it have the financial support or structure to do so.

An infrastructure is needed to gain national consensus on: what to measure, how to define the measures, how to collect the data and survey for events, what is the accuracy of EHRs as a source of performance, the cost-effectiveness of various measures, how to reduce the costs of data collection, how to define thresholds for measures regarding their accuracy, and how to prioritize the measures collected (informed by the relative value of the information collected and the costs of data collection).

Despite this broad research agenda, there is little research funding to advance the basic science of performance measurement. Given the anticipated broad use of measures throughout the health system, funding can be a public/private partnership modeled after the Patient-Centered Outcomes Research Institute or a federally-funded initiative, perhaps centered at AHRQ. Given budgetary constraints, finding the funding to support the science of measurement will be a challenge. Yet, the costs of misapplication of measures and incorrect judgments about performance are substantial.

Continue reading “6. Invest in the basic science of measurement development and applications.”

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Performance measurement has too often been plagued by inordinate focus on technical aspects of clinical care—ordering a particular test or prescribing from a class of medication—such that the patient’s perspective of the care received may be totally ignored. Moreover, many patients, even with successful treatment, too often feel disrespected. Patients care not only about the outcomes of care but also and their personal experience with care.

There is marked heterogeneity in the patient experience, and the quality of attention to patients’ needs and values can influence their course, whether or not short-term clinical outcomes are affected. Some patients have rapid recovery of function and strength, and minimal or no symptoms. Other patients may be markedly impaired, living with decreased function, substantial pain, and other symptoms, and with markedly diminished quality of life. It would be remiss to assume that these two groups of patients have similar outcomes just because they have avoided adverse clinical outcomes such as death or readmission.

In recommending a focus on measuring outcomes rather than care processes, we consider surveys or other approaches to obtaining the perspectives of patients on the care they receive to be an essential component of such outcomes. When designed and administered appropriately, patient experience surveys provide robust measures of quality, and can capture patient evaluation of care-focused communication with nurses and physicians [24]. And while patient-reported measures appear to be correlated with better outcomes, we believe they are worth collecting and working to improve in their own right, whether or not better experiences are associated with improved clinical outcomes [25].

Continue reading “4. Measure patient experience with care and patient-reported outcomes as ends in themselves.”

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It has been a couple of weeks since the landmark Oregon Experiment paper came out, and the buzz around it has subsided.  So what now?  First, with passage of time, I think it is worth reflecting on what worked in Oregon.  Second, we should take a step back, and recognize that what Oregon really exposed is that health insurance is a small part of a much bigger story about health in general.  This bigger story is one we can’t continue to ignore.

So let’s talk quickly about what worked in Oregon.  Health insurance, when properly framed as insurance (i.e. protection against high, unpredictable costs) works because it protects people from financial catastrophe.  The notion that Americans go bankrupt because they get cancer is awful and inexcusable, and it should not happen. We are a better, more generous country than that.  We should ensure that everyone has access to insurance that protects against financial catastrophe.  Whether we want the government (i.e. Medicaid, Medicare) or private companies to administer that insurance is a debate worth having.  Insurance works for cars and homes, and the Oregon experiment makes it clear that insurance works in healthcare.  No surprise.

The far more interesting lesson from Oregon is that we should not oversell the value of health insurance to improving people’s health.  While health insurance improves access to healthcare services (modestly), its impact on health is surprisingly and disappointingly small.  There are two reasons why this is the case.  The first is that not having insurance doesn’t actually mean not having any access to healthcare.  We care for the uninsured and provide people life-saving treatments when they need it, irrespective of their ability to pay.  Sure – we then stick them with crazy bills and bankrupt them – but we generally do enough to help them stay alive.  Yes, there’s plenty of evidence that the uninsured forego needed healthcare services and the consequences of being uninsured are not just financial.  They have health consequences as well.  But, claims like 50,000 Americans die each year because of a lack of health insurance? The data from Oregon should make us a little more skeptical about claims like that.

So what really matters?  Right now, we are pouring $2.8 trillion into healthcare services while failing to deliver the basics.  To borrow a well-known phrase, our healthcare system is perfectly designed to produce the outcomes we get – and here’s what we get: mediocre care and lousy outcomes at high prices.  Great.

Continue reading “The Oregon Experiment Revisited”

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