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
American consumers know more about the quality and prices of restaurants, cars, and household appliances than they do about their health care options, which can be a matter of life and death. While we have made some progress in getting consumers reliable quality information thanks to organizations like Bridges to Excellence and The Leapfrog Group, for most Americans, shockingly little information still exists about health care prices, even for the most basic services. And several studies have shown us that the price for an identical procedure can vary as much as 700 percent with no difference in quality. Moreover, with health care comprising 18 percent of the US economy and costs rising every day, it is extremely troubling that most health care prices are still shrouded in mystery.
Our organizations have been steadily pushing health plans and providers to share price information more freely, and we are seeing progress. But public policy—or even just pending legislation—can provide a powerful motivator as well.
Unfortunately, our new Report Card on State Price Transparency Laws shows most states are not doing their part to help consumers be informed and empowered to shop for higher value care. In the Report Card released Monday, 72 percent of states failed, receiving a “D” or an “F.” Just two, Massachusetts and New Hampshire, received an “A.” The Report Card based grades on criteria including: sharing information about the price of both inpatient and outpatient services; sharing price information for both doctors and hospitals; sharing data on a public website and in public reports; and allowing patients to request pricing information prior to a hospital admission.
Continue reading “States Must Step Up to Help Consumers Gain Access to Health Care Prices”
Filed Under: OP-ED, THCB, The Business of Health Care
Tagged: Catalyst for Payment Reform, consumer-patients, Costs, Francois de Brantes, Health Care Incentives Improvement Institute, Hospitals, Massachusetts, New Hampshire, Quality, Suzanne Delbanco, The States, Transparency
Mar 18, 2013
Not long ago the Atlantic published a provocative article entitled “The Robot Will See You Now.” Using the supercomputer Watson as a starting point, the author explored the mind-bending possibilities of e-care. In this near future, so many aspects of medicine will be captured by automated technology that the magazine asked if “your doctor is becoming obsolete?”
The IT version of health includes continuous medical monitoring (i.e. your watch will check all vital functions), robotic surgery without human supervision, lifelong personal database with genetic code core and intensive preventive care modeled for each person’s need; all supervised by artificial intelligence with access to a complete file of medical research and findings. The e-doctor will never forget, never get tired, never get confused, never take a day off and will give 24/7 medical care at any location, anywhere in the world, for a fraction of the cost. Perfect care, everywhere, at every moment, for a pittance.
While the transformation for doctors seems clear, a shift from being at the core of medicine to being what the article described as “super-quality-control officers,” what intrigues me is not how doctors will change (retire); the real question is how patients will adapt to this new healthcare world? Particularly when experiencing extreme or life threatening illness, will patients accept that family, friends and a pumped up Ipad are enough?
Continue reading “Death By Remote Connection”
Filed Under: Uncategorized
Tagged: e-care, End of Life Care, HIT, Hospice, Jonathan Cohn, Quality, supercomputer
Mar 11, 2013
“What does the 21st Century Physician look like?”
Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.
I’ll admit that the question on the face of it struck me as a bit absurd, especially when juxtaposed with the term “tomorrow’s doctor.”
Tomorrow’s doctor needs to be doing a much better job of dealing with today’s medical challenges, because they will all be still here tomorrow. (Duh!) And the day after tomorrow.
(As for the 21st century in general, given the speed at which things are changing around us, seems hard to predict what we’ll be doing by 2050. I think it’s likely that we’ll still end up needing to take care of elderly people with physical and cognitive limitations but I sincerely hope medication management won’t still be a big problem. That I do expect technology to solve.)
After looking at the related Huffington Post piece, however, I realized that this trio really seems to be thinking about how medical education should be changed and improved. In which case, I kind of think they should change their organization’s name to “Next Decade’s Doctor,” but I can see how that perhaps might not sound catchy enough.
Continue reading “What Will Tomorrow’s Doctor Look Like?”
Filed Under: Physicians, THCB
Tagged: CQI, e-patients, FutureMed, Leslie Kernisan, Medical Education, OpenNotes, PDSA, practice of medicine, Quality, shared decision making, TEDMED
Mar 8, 2013
There’s been a great deal of discussion about health care payment reform. Prominent in this discussion is “Pay for Performance” (P4P). The idea is simple — rather than pay providers based on volume of care (fee-for-service) or number of patients (capitation), tie their payment to a measure(s) of performance. There has been substantial concern about the quality of care delivered to patients, so pay for performance appears to make a lot of sense. Don’t we want to reward providers for good performance? Shouldn’t this encourage them to provide high quality care?
Unfortunately, this is not as straightforward as it might appear. While the idea of pay for performance is very appealing and intuitive, there are some major pitfalls in implementation.
Continue reading “The Promises and Pitfalls of Pay for Performance”
Filed Under: Hospitals, The Business of Health Care
Tagged: health economics, Hospitals, Incentives, Martin S. Gaynor, Medicare, Pay for Performance, payment reform, Quality
Mar 3, 2013
In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in – well, actually, poured in not that much money at all when you think about it – lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.
Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.
The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.
Continue reading “The Health IT Scandal the NY Times Didn’t Cover”
Filed Under: Tech, THCB
Tagged: EHR, EHR adoption, HIT, Hospitals, Innovation, Meaningful Use, Michael Millenson, Patient Safety, Physicians, Quality
Mar 3, 2013
Several email lists I am on were abuzz last week about the publication of a paper that was described in a press release from Indiana University to demonstrate that “machine learning — the same computer science discipline that helped create voice recognition systems, self-driving cars and credit card fraud detection systems — can drastically improve both the cost and quality of health care in the United States.” The press release referred to a study published by an Indiana faculty member in the journal, Artificial Intelligence in Medicine .
While I am a proponent of computer applications that aim to improve the quality and cost of healthcare, I also believe we must be careful about the claims being made for them, especially those derived from results from scientific research.
After reading and analyzing the paper, I am skeptical of the claims made not only by the press release but also by the authors themselves. My concern is less about their research methods, although I have some serious qualms about them I will describe below, but more so with the press release that was issued by their university public relations office. Furthermore, as always seems to happen when technology is hyped, the press release was picked up and echoed across the Internet, followed by the inevitable conflation of its findings. Sure enough, one high-profile blogger wrote, “physicians who used an AI framework to make patient care decisions had patient outcomes that were 50 percent better than physicians who did not use AI.” It is clear from the paper that physicians did not actually use such a framework, which was only applied retrospectively to clinical data.
What exactly did the study show? Basically, the researchers obtained a small data set for one clinical condition in one institution’s electronic health record and applied some complex data mining techniques to show that lower cost and better outcomes could be achieved by following the options suggested by the machine learning algorithm instead of what the clinicians actually did. The claim, therefore, is that if the data mining were followed by the clinicians instead of their own decision-making, then better and cheaper care would ensue.
Continue reading “Data Mining Systems Improve Cost and Quality of Healthcare – Or Do They?”
Filed Under: Tech, Uncategorized
Tagged: Artificial intelligence, CDOI, client-directed outcome informed assessment, Costs, Data, data mining systems, HIT, Informatics, Physicians, Quality, William Hersh
Feb 24, 2013
Should we hold hospitals accountable for what happens after a patient leaves the hospitals’ doors? A year ago, I thought the answer was no. A hospital’s job was to take care of sick patients, make them better and send them on their way. With more thought and consideration, I have come to conclude that I was probably wrong. It may be perfectly reasonable to hold hospitals accountable for care beyond their walls, but we should be clear why we’re doing it. Readmissions are not a good quality measure – but they may be a very good way to change the notion of accountability within the healthcare delivery system.
The debate around the readmissions measure has come to the forefront because of the CMS Hospital Readmission Reduction Program, which penalizes hospitals for “greater than expected” readmission rates. It has raised the question — does a hospital’s 30-day readmission rate measure the “quality of care” it provides? Over the last three years, the evidence has come in, and to my read, it is unequivocal. By most standards, the readmissions metric fails as a quality measure.
Why do I say that readmissions are a poor measure of hospital quality? First, we have to begin by thinking about what makes a good quality measure. Quality is about the essence of the thing being produced – a good or a service. The job of a car is to get you from place A to place B and a high-quality car may be one that does the job reliably, safely, or maybe even comfortably. The job of a restaurant is to provide a meal that you don’t have to cook — and a high quality restaurant may provide food that is fresh, tasty, or with an attention to service that you enjoy. What is the job of a hospital? When you get sick and require hospital services, a high-quality hospital should give you the right treatments, attend to your needs while you’re there, and make sure nothing bad (i.e. a new nosocomial infection) happens along the way. That’s how we measure hospital quality.
Quality measures for healthcare come in three flavors – structural measures (do you have enough intensivists manning your ICU?), processes measures (did you give the heart attack patient his or her aspirin?) and outcomes measures (did the pneumonia patient die?). The elemental part of both structural measures and process measures is that they have to be tied to an outcome we care about. If having more intensivists in the ICU does not lead to lower ICU mortality (or lower complication rates), we wouldn’t think it’s a particularly good quality measure. We know that giving aspirin to heart attack patients lowers their chances of dying by 25%. We have multiple randomized trials. We don’t need much more evidence. Hospitals that have the right structures in place and reliably deliver the right treatments can reasonably be called high-quality hospitals.
Continue reading “The 30-day Readmission Rate: Not a Quality Measure but an Accountability Measure”
Filed Under: Hospitals, THCB
Tagged: Accountability, accountability metrics, Ashish Jha, CMS, CMS Hospital Readmission Reduction Program, Hospitals, JAMA, Quality, quality metrics, Readmission Rates
Feb 14, 2013
Over the past decade, there has been yet another debate about whether pay-for-performance, the notion that the amount you get paid is tied to some measure of how you perform, “works” or not. It’s a silly debate, with proponents pointing to the logic that “you get what you pay for” and critics arguing that the evidence is not very encouraging. Both sides are right.
In really simple terms, pay-for-performance, or P4P, can be thought about in two buckets: the “pay” part (how much money is at stake) and the “performance” part (what are we paying for?). So, in this light, the proponents of P4P are right: you get what you pay for. The U.S. healthcare system has had a grand experiment with P4P: we currently pay based on volume of care and guess what? We get a lot of volume. Or, thinking about those two buckets, the current fee-for-service structure puts essentially 100% of the payments at risk (pay) and the performance part is simple: how much stuff can you do? When you put 100% of payments at risk and the performance measure is “stuff”, we end up with a healthcare system that does a tremendous amount of stuff to patients, whether they need it or not.
Against these incentives, new P4P programs have come in to alter the landscape. They suggest putting as much as 1% (though functionally much less than that) on a series of process measures. So, in this new world, 99%+ of the incentives are to do “stuff” to patients and a little less than 1% of the incentives are focused on adherence to “evidence-based care” (though the measures are often not very evidence-based, but let’s not get caught up in trivial details). There are other efforts that are even weaker. None of them seem to be working and the critics of P4P have seized on their failure, calling the entire approach of tying incentives to performance misguided.
The debate has been heightened by the new national “value-based purchasing” program that Congress authorized as part of the Affordable Care Act. Based on the best of intentions, Congress asked Medicare to run a program where 1% of a hospital’s payments (rising to 2% over several years) is tied to a series of process measures, patient experience measures, and eventually, mortality rates and efficiency measures. We tried a version of this for six years (the Premier Hospital Quality Incentives Demonstration) and it didn’t work. We will try again, with modest tweaks and changes. I really hope it improves patient outcomes, though one can understand why the skeptics aren’t convinced. Continue reading “Getting Pay-For-Performance Right”
Filed Under: Hospitals, THCB
Tagged: Ashish Jha, Hospitals, Incentives, JAMA, Medicare, Outcomes, Pay for Performance, PPACA, Quality, Transparency, Value-based Purchasing
Feb 4, 2013
If you study misdiagnosis you realize how often patients get the wrong diagnosis.
But what do expert doctors think about how often it happens? And what do they think can be done to address it?
We wanted to find out so we partnered with the National Coalition on Healthcare to conduct a landmark, nationwide survey. We surveyed 400 cancer specialists from our Best Doctors database – and the findings were provocative.
The survey, “Exploring Diagnostic Accuracy in Cancer: A Nationwide Survey of 400 Leading Cancer Specialists,” focused on what doctors believe to be the most significant barriers in efforts to accurately diagnose cancers; the types of cancer they believe are most often misdiagnosed; and the tools and improvements they most need to combat misdiagnosis.
One of the most surprising findings was on how often doctors believe misdiagnosis happens. While published studies show that misdiagnosis occurs in about 15-28% of cases, the large majority of doctors we surveyed thought it happens in less than 10% of cases. At the same time, doctors recognized that the root causes of misdiagnosis were very prevalent – fragmented medical information, disparities in experience among pathologists and other factors.
So – how to explain the difference in doctors’ perceptions and the published research? I think it is because there is no systematic feedback loop for doctors letting them know of inaccuracies in their care. If you diagnose someone and they go on to get treatment someplace, and it’s later discovered that a diagnosis wasn’t exactly right, the original doctor may never find out about it. If you don’t hear about it, you can’t be blamed for thinking this problem is rare. It also means you miss out on the opportunity to improve the quality of care that these cases represent.
Another interesting point. Doctors reported that, regardless of how often they thought diagnostic inaccuracies happened, it is a problem that needed more attention from policy-makers. As NCHC President and CEO John Rother observed, “Not enough is being done on the state and federal policy end of things to acknowledge and firmly address this critical issue. Given our current health care climate and challenges, as decision-makers become more aware of the frequency of misdiagnosis and the enormous costs associated with it, they have a sizeable opportunity to make diagnostic accuracy much more of a ‘front and center’ issue in health care.”
Here’s to that promising thought.
Evan Falchuk is Vice Chairman of Best Doctors, Inc., where this post originally appeared. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases. This post originally appeared on Best Doctors, Inc.’s See First Blog.
Filed Under: Hospitals, THCB
Tagged: Evan Falchuk, John Rother, Misdiagnosis, National Coalition on Healthcare, Physicians, Policy, Quality
Feb 1, 2013