Partners Healthcare

Jeff GoldsmithSometimes big game hunters find frustration when their prey moves by the time they’ve lined up to blast it. That certainly appears to be the case with the health policy target de jour: whether providers, hospital systems in particular, exert too much market power. A recent cluster of papers and policy conferences this spring have targeted the question of whether hospital mergers have contributed to inflation in health costs, and what to do about them.

Hospitals’ market power appears to be one of those frustrating moving targets. The past eighteen months have seen a spate of hospital industry layoffs by market-leading institutions, and also a string of terrible earnings releases from some of the most powerful hospital systems and “integrated delivery networks” in the country. These mediocre operating results raise questions about how much market power big hospital systems and IDNs do, in fact, exert.

The two systems everyone points to as poster children for excessive market power-California-based Sutter Health and Boston’s Partners Healthcare, both released abysmal operating results in April. Mighty Partners reported a paltry $3 million in operating income on $2.7 billion in revenues in their second (winter) quarter of FY14. Partners cited a 4.5 percent reduction in admissions and a 1.6 percent decline in outpatient visits as main drivers. Captive health insurance losses dragged down Partners’ patient care results. Sutter did even worse, losing $22 million on operations in FY13 (ended in December), — compared to a gain of $697 million in FY11 — on more than $9.6 billion in revenues.  A 3 percent decline in admissions led to FY13 revenue growth of 0.9 percent (that is, nine-tenths of one percent), against 7.3 percent in expense growth.

These results were not atypical. After Sutter, the second most powerful health system in the West, Seattle-based Providence Health and Services, had $37.7 million in operating earnings in FY13 — compared to $239 million in 2011 — on $11 billion in revenues and essentially flat admissions. While some of these results were clearly affected by Providence’s take-over of the failing Swedish Health System in Seattle, there were broad declines in revenue growth across the system. Henry Ford Health System in Detroit, one of the nation’s first hospital-based integrated delivery networks, lost $12 million on operations in FY13 (before some one-time accounting changes), on $4.6 billion in revenues, and hadonly $75,000 in total system revenue growth. Expense increases of 2.6 percent effectively wiped out earnings.

Continue reading “How Much Market Power Do Hospitals Really Have?”

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The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits.  A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died.  This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state.  It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security: Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call.  That would seem to protect patient privacy.  At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit.  Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted.  I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care.  Can a Skype call substitute for an in-person visit?  Under what circumstances?

Video virtual visits are a new mode of care delivery.  Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care.  That same rigor applies to video virtual visits.  Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming.  I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.

We have believed for some time that this technology should be limited to follow up visits, where the patient and physician already have a well-established relationship.  Technologies such as Skype and Facetime allow for a robust conversation, but most doctors’ visits require much more than just conversation.  For example, any time a physical exam is required, this technology will not work well.  That’s why one of our first pilot studies was to implement video technology for mental health follow up visits (as did the doctor in Oklahoma).

Our early results are promising.  It seems that virtual video visits for mental health offer both the provider and the patient important benefits.  For many mental health patients, it can be stressful to travel to the doctor’s office.  When a patient is being evaluated for a medication adjustment, for example, they are not at their best.  The convenience of having a follow-up visit from their own home can be a big lift for these patients.  On the other hand, doctors often feel that the home environment is particularly relevant in sorting out mental health problems.  A virtual visit allows them to, in effect, conduct a virtual house call.

Continue reading “A Physician Faces Disciplinary Action For Seeing Patients on Skype — Early Guidelines For Patient Video Visits”

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Does anyone in their right mind believe that these are the best of times in healthcare or health IT?

Scratch that.

Does anyone besides Judy Faulkner and Neal Patterson believe these are the best of times? (I mean, everyone knows that Dramatic Transition + Industry-wide Upheaval + Piles of Cash = Satisfaction / Contentment, proving the point mathematically.)

The question: At what cost to overall healthcare improvement do Epic and Cerner (and others, to be fair … except you, Allscripts) reap massive profits?

The short answer: We don’t really know.

While it is generally acknowledged by most (certainly not all, which you know if you’ve spent any time on HIStalk) that the ready availability and automated cross-checking of electronic health records improves care, there is no definitive study showing dramatic clinical improvement, demonstrable return on investment, etc.

Indeed, we now have a number of studies suggesting exactly the opposite:

Continue reading “A Tale of Two Studies: What Are the Actual Costs of an EHR?”

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After a seemingly endless presidential campaign, we’re just days away from the Nov. 6 election. And to be sure, health care issues remain at the forefront.

Both Barack Obama and Mitt Romney have tried to claim the high ground as Medicare’s number one defender. In his latest column, the New York Times’ Paul Krugman argues that next week’s vote “is, to an important degree, really about Medicaid.” And writing on Bloomberg View, columnist Ezra Klein takes an even broader stance, concluding that “this election is all about health care.”

But health care isn’t all about the election, despite politics’ seeming ability to draw every sector into its gravitational pull.

In fact, many of the most significant stories in health care from the past two months haven’t come from the campaign trail — where candidates have mostly rehashed their existing policies — but from the private sector, as employers and providers have made aggressive, and sometimes unexpected, deals and changes. Reforms that will continue regardless of who’s sitting in the Oval Office next year.

Here are some of those stories.

Top Employers Move to Defined Contribution

As previously discussed in “Road to Reform,” Sears Holdings and Darden Restaurants have made plans to shift away from their current “defined benefits” — where they choose a set of health insurance benefits on behalf of their workers — and roll out “defined contribution” instead.

Under that model, firms pay a fixed amount for employees’ health benefits and allow workers to choose their coverage from an online marketplace, such as the Affordable Care Act’s health insurance exchanges or the emerging number of privately run exchanges.

In theory, the model would slow employers’ health costs while allowing employees to have more control over their own health care spending. And Sears and Darden’s announcements aren’t wholly unexpected, given that many employers have signaled their interest in making a similar shift.

But given the long-entrenched employer-sponsored health coverage model, some employers needed to be the first movers before the rest would be ready to follow.

Will they? That will be a major industry issue to watch across the next months.

Continue reading “How Health Care Changed While You Were Watching the Election”

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(Note: the following commentary was co-authored with Tory Wolff, a founding partner of Recon Strategy, a healthcare strategy consulting firm in Boston; Tory and I gratefully acknowledge the insightful feedback provided by Jay Chyung of Recon Strategy.)

Medicine has been notoriously slow to embrace the electronic medical record (EMR), but, spurred by tax incentives and the prospect of cost and outcomes accountability, the use of electronic medical records (EMRs) is finally catching on.

There are a large number of EMR vendors, who offer systems that are either the traditional client server model (where the medical center hosts the system) or a product which can be delivered via Software as a Service (SaaS) architecture, similar to what salesforce.com did for customer relationship management (CRM).

Historically, the lack of extensive standards have allowed hospital idiosyncrasies to be hard-coded into systems.  Any one company’s EMR system isn’t particularly compatible with the EMR system from another company, resulting in – or, more fairly, perpetuating – the Tower of Babel that effectively exists as medical practices often lack the ability to share basic information easily with one another.

There’s widespread recognition that information exchange must improve – the challenge is how to get there.

One much-discussed approach are health information exchanges (HIE’s), defined by the Department of Health and Human Services as “Efforts to rapidly build capacity for exchanging health information across the health care system both within and across states.”

With some public funding and local contributions, public HIE’s can point to some successes (the Indiana Health Information Exchange, IHIE, is a leading example, as described here).  The Direct Project – a national effort to coordinate health information exchange spearheaded by the Office of the National Coordinator for Health IT – also seems to be making progress.  But the public HIEs are a long way from providing robust, rich and sustainable data exchange.

Continue reading “What The Emergence of an EMR Giant Means For the Future of Healthcare Innovation”

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