Recently, a jury awarded a young California resident $28.2 million for a delayed diagnosis of a pelvic tumor. The jury found Kaiser Permanente (KP) negligent. Doctors in the system, touted to be one of the finest systems by the President, allegedly refused an immediate MRI for back pain in a 17 year old. The patient eventually received an MRI three months after presentation, which found a tumor so extensive that the patient needed an amputation.
The case is instructive at multiple levels. It shows a tense dialectic between the individual and society. It also highlights a truism that many don’t understand or don’t acknowledge – missed/ delayed diagnosis and waste are reciprocal. They’re birds of a feather. You can’t have less of one without more of the other.
The patient presented with back pain. MRI for back pain is the poster child of waste. Why so? Because so many are negative. Even more are meaninglessly positive –disc bulges which simply mean “I’m Homo sapiens and I wasn’t intelligently designed to be sitting at the desk.”
High quality doctors don’t order MRI for back pain immediately, reflexively and incontinently. Think about this. A high quality doctor should say “I don’t think you need an MRI because it won’t change the management and doesn’t improve outcomes.” That’s the resounding message from the top. If it doesn’t improve outcomes it’s not a worthy test. High quality doctors will, once in a while, cost their organization a lot of money.
But quality is still not settled. Quality doctors must satisfy patients. If a patient asks for an MRI for back pain the quality doctor must acquiesce, if that refusal dissatisfies. I’m confused. Ordering an MRI for back pain is poor care. But not ordering an MRI for back pain is poor care. Which is it?
We don’t know the facts of the case. It’s possible that the patient had a neurological deficit that should have raised the urgency. It’s possible that the physician didn’t examine the patient and had he/ she examined, the tumor might have been detected. We don’t know. We shouldn’t judge (1). Continue reading “The High Cost of Reducing Waste in US Healthcare”
Filed Under: THCB
Tagged: Kaiser Permanente, MRI, Quality, Radiology
Mar 29, 2015
Chief information officers (CIOs) and chief medical information officers (CMIOs) have spent the better part of two decades on a quest for interoperability; yet, their Achilles heel lies in the “information” part of their titles. If information is the sole beacon of efficiency and value, the invaluable contours of human suffering, personal preferences and humanity itself are lost.
Information is the first step to developing knowledge and understanding, but what physicians and patients rely on in the real clinical setting, rife with changes, are knowledge, understanding and empathy. The cold, hard calculus of a=b does not always apply when dealing with people because they are much more complex and complicated than binary machines with screens. If it were so easy, there would be no problem reaching 100% compliance with medication or a plan of action.
Sadly, all data lives in a database; which might as well be called a wait-a-base; after all, the data just sits there and waits for someone to look at it.
The fundamental problem with today’s information architecture is that all data are not created equal. Data, information and knowledge degrade with each new doctor that becomes involved. In addition, systems design lacks an understanding of how the human computer works in the context of illness, anxiety or uncertainty. Healthcare is a people business in need of data, not a data business in need of people. Data are the means; people are the beginning and the end.
Continue reading “Why Data Handoffs Matter”
Filed Under: Tech, THCB
Tagged: Cost, Data, Data Handoffs, Medical Claims, Quality
Mar 9, 2015
The U.S. Department of Health and Human Services’ recent announcement to move the Medicare program toward value-based payments is among the most promising recent developments in health care.
While changing the way we pay for care will not be easy, we believe that shifting away from fee-for-service to value-based payments could be a catalyst to a better, more affordable health care system in our country.
Three Benefits of Paying for Quality
There are numerous potential benefits to paying for quality rather than quantity, including the three we want to focus on today.
- We believe this payment shift has the potential to accelerate progress toward achieving the Triple Aim – defined as better individual care, better population care, and lower cost.
- We believe the payment shift by Medicare will accelerate the transition to value-based payments among commercial insurers – a major benefit to employers in terms of improved health for employees and greater affordability.
- We believe value-based payments have the potential to help slow – and possibly reverse – the epidemic of physician burnout in the United States, particularly among primary care doctors. Continue reading “Value-Based Reform”
Filed Under: OP-ED, THCB
Tagged: Employers, Fee-for-service, Medicare, payment reform, physician burnout, Quality, Triple Aim
Mar 2, 2015
While your correspondent is tantalized by the prospect of healthcare consumers using mHealth apps to lower costs, increase quality and improve care, he wanted to better understand their real-world value propositions.
Are app-empowered patients less likely to use the emergency room?
Do they have a higher survival rate?
Do they have higher levels of satisfaction?
In other words, where’s the beef?
That’s when this paper caught my search engine eye. It’s a report on using an app to monitor post-operative patients at home. Continue reading “Using a Mobile App for Monitoring Post-Operative Quality of Recovery”
Filed Under: Patients, THCB
Tagged: Apps, EHR, Pain, Patient Satisfaction, Post operative patients, Quality, Recovery
Mar 2, 2015
No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind. But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.
The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies. As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.
Here’s an example. An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result. Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees. Some are paying attention to the new rule, and many others are ignoring it. One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.
Continue reading “Germs. The Pseudoscience of Quality Improvement”
Filed Under: OP-ED, THCB
Tagged: Doctors, Hand washing, Hygiene hypothesis, Infection Prevention, iPads, iPods, JCAHO, Nursing, OR, Quality, Rules
Dec 7, 2014
I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.
So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.
1) Doctors are People
No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.
Continue reading “A Doctor is a Doctor is a Doctor, Right?”
Filed Under: Physicians, Small Practice
Tagged: Doctors, primary care, Quality, Small Practice, Workplace culture
Dec 5, 2014
A number of pundits are citing the systemic failure of ACOs, after additional Pioneer ACOs announced withdrawal from the program – Where do you weigh in on the prognosis for Medicare and Commercial ACOs over the next several years?”
Peter R. Kongstvedt
Whoever thought that by themselves, ACOs would successfully address the problem(s) of [cost] [access] [care coordination] [outcomes] [scurvy] [Sonny Crockett's mullet in Miami Vice Season 4]? The entire history of managed health care is a long parade of innovations that were going to be “the answer” to at least the first four choices above (Vitamin C can cure #5 but sadly there is no cure for #6). Highly praised by pundits who jump in front of the parade and declare themselves to be leaders, each ends up having a place, but only a place, in addressing our problematic health system.
The reasons that each new innovative “fix” end up helping a little but not occupying the center vary, but the one thing they all have in common is that the new thing must still compete with the old thing, and the old thing is there because we want it there, or at least some of us do. The old thing in the case of ACOs is the existing payment system in Medicare and by extension, our healthcare system overall because for all the organizational requirements, ACOs are a payment methodology.
Continue reading “ACOs Are Doomed / No They’re Not”
Filed Under: Tech, THCB
Tagged: Accountable Care Organizations, Care, Care coordination, Cyndy Nayer, Medicare Advantage, Network, Pioneer ACOs, PPO, Quality, Sonny Crockett's Mullet, Vince Kuraitis
Nov 4, 2014
Accountable care demands that the system sync with the preferences and choices of the consumer purchasing the services. In order to get to real health value, consumer-patients must make the health care decisions that improve personal health and do not derail personal bank accounts. It was hard to piece these together for the last 15 years. Now, with high deductible plans, more transparency for costs, and on-time digital connectivity, there is less difficulty.
Information technology can deliver the needed information to the patient and the physician to improve not only the likelihood of improved care but also the time-to-achieve the outcomes. Most patients want and need to be involved in their care. There is evidence that giving patients access to their information results in higher levels of engagement and adherence to recommendations. In fact, the latest evidence shows that patients have been signing up for access to their health system portals at a rate of 1% per month for over 30 months.
Continue reading “Health Value: IT and the Rise of Consumer Centricity”
Filed Under: THCB
Tagged: Center for Health Engagement, Engagement, Outcomes, Quality, Value, value-based care
Oct 21, 2014
I’m sorry I haven’t had a chance to blog in a while – I took a new job as the Director of the Harvard Global Health Institute and it has completely consumed my life. I’ve decided it’s time to stop whining and start writing again, and I’m leading off with a piece about adjusting for socioeconomic status. It’s pretty controversial – and a topic where I have changed my mind. I used to be against it – but having spent some more time thinking about it, it’s the right thing to do under specific circumstances. This blog is about how I came to change my mind – and the data that got me there.
Changing my mind on SES Risk Adjustment
We recently had a readmission – a straightforward case, really. Mr. Jones, a 64 year-old homeless veteran, intermittently took his diabetes medications and would often run out. He had recently been discharged from our hospital (a VA hospital) after admission for hyperglycemia. The discharging team had been meticulous in their care. At the time of discharge, they had simplified his medication regimen, called him at his shelter to check in a few days later, and set up a primary care appointment. They had done basically everything, short of finding Mr. Jones an apartment.
Ten days later, Mr. Jones was back — readmitted with a blood glucose of 600, severely dehydrated and in kidney failure. His medications had been stolen at the shelter, he reported, and he’d never made it to his primary care appointment. And then it was too late, and he was back in the hospital.
The following afternoon, I spoke with one of the best statisticians at Harvard, Alan Zaslavsky, about the case. This is why we need to adjust quality measures for socioeconomic status (SES), he said. I’m worried, I said. Hospitals shouldn’t get credit for providing bad care to poor patients. Mr. Jones had a real readmission – and the hospital should own up to it. Adjusting for SES, I worried, might create a lower standard of care for poor patients and thus, create the “soft bigotry of low expectations” that perpetuates disparities. But Alan made me wonder: would it really?
To adjust or not to adjust?
Because of Alan’s prompting, I re-examined my assumptions about adjustment for SES. As he walked me through the data, I concluded that the issue of adjustment was far more nuanced than I had appreciated.
Continue reading “Changing My Mind on SES Risk Adjustment”
Filed Under: THCB
Tagged: Ashish Jha, Harvard Global Health Initiative, homeless, JAMA, Quality, Risk adusted, SES, Socioeconomic Status, Veteran
Sep 29, 2014
An advantage of being a foreigner, or a recent immigrant to be precise, is that it allows one to view events with a certain detachment. To analyze without the burden of love, hate or indifference for the Kennedys, the Clintons or the Bushes. To observe with both eyes open, rather than one eye looking at the events and the other looking at a utopian destination.
The most striking thing I’ve observed in the healthcare debate in the US is the absence of an honest discussion of trade-offs.
I’ve found that “trade-off” carries a sinister connotation in American healthcare parlance. Its mere utterance is a defeatist’s surrender. If optimism is the iron core of the United States, acknowledging trade-offs is her kryptonite.
I was raised in Britain. I learnt to guard optimism with pursed lips. You never knew when it would rain. I also learnt in Britain’s NHS where healthcare resources really are finite, there is a trade-off between coverage and access.
In the discussions preceding the implementation of the Affordable Care Act (ACA) two disparate truths were conjoined by a single solution. The unsustainable trajectory of healthcare spending. And the large number of uninsured population. It was scarcely acknowledged that solution of these problems are inherently oppositional.
This has led to the search for utopian payment models. Fee for service incentivizes physicians towards generously reimbursable services of marginal benefits. Capitated systems dissuade physicians from taking sicker patients.
How about we pay for outcome, value and quality? Sounds simple enough.
Continue reading “It’s a Trade-Off, Stupid.”
Filed Under: Economics, THCB
Tagged: Debate, Outcome, Quality, Trade-Off, Value
Sep 25, 2014