As the fashionistas might say, transparency in health care is having a moment. It made the PricewaterhouseCoopers top 10 list for 2014 industry issues, and there is every reason to expect transparency to be very visible this year and beyond.
Without a doubt, transparency is hot.
Despite this, there is increasing grumbling by observers who say that transparency is complicated and hard to operationalize. We also hear that transparency is “not enough” to constrain costs in our dysfunctional system, especially in the face of provider market power.
The word itself invites skepticism, in that it seems to over-simplify and promise a magical solution, as if daylight will provide health care pricing with a glow of rationality.
As usual, the truth lies somewhere in the middle. Transparency can and will provide information about price, quality, and consumer experience that market participants need in order to better understand the health care system and increase its value.
While this information is surely necessary, we have seen many examples of when it is not sufficient. Clearly, transparency is not the only tool that we need.
Here are a few thoughts about transparency issues for 2014.
Transparency tools will hit Main Street.
Increasingly, consumer-facing tools with various kinds information about health care prices are being created, whether it is okcopay or Change Healthcare. These entries join a growing list of transparency tools from carriers or third-party vendors.
The Robert Wood Johnson Foundation’s Hospital Price Transparency challenge, designed to promote awareness of hospital charge data, had a record number of entrant and the winning submissions are downright inspiring. RWJF also awarded grants for research on the use of price data in health care, including a number of studies of promising transparency tools aimed at consumers and providers.
The field is becoming more crowded, and it is increasingly important to determine the optimal way to reach the consumer with price and quality information.
There will be greater focus on the customer experience.
There is no doubt that the customer experience in health care lags behind the rest of the service sector, and consumers are increasingly demanding responsiveness and convenience in their encounters with the medical profession. The growth of evening and weekend hours, email communications with physicians, and patient portals are all harbingers of a new age where medicine is far more customer friendly.
RWJF’s Open Notes initiative allows patients to share notes with their doctors, while the Foundation’s Flip the Clinic program completely reimagines the doctor patient encounter in the ambulatory care setting.
Continue reading “Transparency a Go Go?”
Filed Under: Uncategorized
Tagged: Chargemaster, Choosing Wisely, consumer driven health, Hospitals, Katherine Hempstead, OpenNotes, RWJF, Transparency, value-based care
Feb 28, 2014
The Obama administration announced significant adoption for the Blue Button in the private sector on Friday.
In a post at the White House Office of Science and Technology blog, Nick Sinai, U.S. deputy chief technology officer and Adam Dole, a Presidential Innovation Fellow at the U.S. Department of Health and Human Services, listed major pharmacies and retailers joining the Blue Button initiative, which enables people to download a personal health record in an open, machine-readable electronic format:
“These commitments from some of the Nation’s largest retail pharmacy chains and associations promise to provide a growing number of patients with easy and secure access to their own personal pharmacy prescription history and allow them to check their medication history for accuracy, access prescription lists from multiple doctors, and securely share this information with their healthcare providers,” they wrote.
“As companies move towards standard formats and the ability to securely transmit this information electronically, Americans will be able to use their pharmacy records with new innovative software applications and services that can improve medication adherence, reduce dosing errors, prevent adverse drug interactions, and save lives.”
While I referred to the Blue Button obliquely at ReadWrite almost two years ago and in many other stories, I can’t help but wish that I’d finished my feature for Radar a year ago and written up a full analytical report.
Extending access to a downloadable personal health record to millions of Americans has been an important, steady shift that has largely gone unappreciated, despite reporting like Ina Fried’s regarding veterans getting downloadable health information.
According to the Office of the National Coordinator for Health IT, “more than 5.4 million veterans have now downloaded their Blue Button data and more than 500 companies and organizations in the private-sector have pledged to support it.”
Continue reading “The Pharmacies and Retailers Say They’re In. Is the Blue Button Initiative About to Change Everything?”
Filed Under: THCB
Tagged: Alex Howard, Blue Button, Blue Button initiative, HHS, HIT, ONC, open data, personal health records, Transparency
Feb 11, 2014
“‘Let’s go.’ ‘We can’t.’ ‘Why not?’ ‘We’re waiting for Godot.’” ― Samuel Beckett
For the economists in our midst, demand is a critical but pretty dry idea: the quantity of a good or service a buyer is willing to purchase at a given price. It’s presumed to be part of working health care markets.
It’s one of the first things an undergraduate might learn in Econ 100.
There’s no urgency in this demand; it just is.
Of course, nothing—even general economic principles—is simple in health care. Still, you can look longingly at a few nice supply and demand curves and dream about how things might be—if only.
If only health care consumers picked up their role and skittered up and down those demand curves.
If only they helped us find those elusive market equilibriums for this health care service or that. For some time, lots of people have seen that enormous and powerful potential—and drooled over it.
We’ve been waiting a long time for our consumer to show up in health care. We’ve been waiting for the consumer to obtain and use the information she needs to demand great care.
We’ve been waiting for lots of consumers to do that over and over to help us out of our unfortunate health care jam.
It’s that jam where we pay too much for lots of care of marginal quality riddled with safety problems and delivered by a bunch of dissatisfied, demoralized health professionals.
Indeed we have been waiting a long time for our health care consumer. Certainly, there have been and continue to be countless reasons why consumers haven’t arrived to help save us.
“Health care is different!”
“There’s no evidence that consumers will behave like normal consumers in health care!”
Continue reading “An Urgent Request”
Filed Under: Health 2.0
Tagged: consumer driven health, HCI3, INQUIREhealthcare, Michael Painter, Transparency
Feb 5, 2014
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”
Filed Under: THCB, The Business of Health Care
Tagged: ACOs, Elliot Fisher, Janet M. Corrigan, Medicare Shared Savings Program, Outcomes, performance metrics, The Dartmouth Atlas Project, Transparency, William L. Schpero
Feb 4, 2014
The Cleveland Clinic is by far the best provider of cardiac care in the nation. If you have cancer there is no better place to be than Texas. Johns Hopkins is the greatest hospital in the America.
Why? Because US News and World Report suggests as much in its hospital rankings.
But which doctors at the Cleveland Clinic have the highest success rates in aortic valve repair surgeries? What are the standardized mortality rates due to cancer at University of Texas MD Anderson Cancer Center? Why exactly is Johns Hopkins the best?
We don’t have answers to these types of questions because in the United States, unlike in the United Kingdom, data is not readily available to healthcare consumers.
The truth is, the rankings with which most patients are familiar provide users with little. Instead, hospitals are evaluated largely by “reputation” while details that would actually be useful to patients seeking to maximize their healthcare experiences are omitted.
Of course, the lack of data available about US healthcare is not US News and World Report’s fault – it is indicative of a much larger issue. Lacking a centralized healthcare system, patients, news sources, and policy makers are left without the information necessary for proper decision-making.
While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting. If you’re a patient in the United Kingdom, you can look up everything from waiting times for both diagnostic procedures and referral-to-treatment all the way to mortality and outcome data by individual physician.
This is juxtaposed to the US healthcare system, where the best sources of data rely on voluntary reporting of information from one private entity to another.
Besides being riddled with issues, including a lack of standardization and oversight, the availability of data to patients becomes limited, manifesting itself in profit-driven endeavors like US News and World Report or initiatives like The Leap Frog Group that are far less well-known and contain too few indicators to be of real use.
The availability of data in the United Kingdom pays dividends. For example, greater understanding of performance has allowed policy makers to consolidate care centers that perform well and close those that hemorrhage money, cutting costs while improving outcomes. Even at the individual hospital level, the availability of patient data keeps groups on their toes.
Continue reading “Why Transparency Doesn’t Work.”
Filed Under: Tech, THCB
Tagged: Alexander Chaitoff, consumer driven health, Data, Hospital rankings, NHS, Patient Safety, Transparency, US News and World Report
Jan 30, 2014
The federal government’s announcement last week that it would begin releasing data on physician payments in the Medicare program seems to have ticked off both supporters and opponents of broader transparency in medicine.
For their part, doctor groups are worried that the information to be released by the Centers for Medicare and Medicaid Services will lack context the public needs to understand it.
“The unfettered release of raw data will result in inaccurate and misleading information,” AMA President Ardis Dee Hoven, MD, said in a statement to MedPage Today. “Because of this, the AMA strongly urges HHS to ensure that physician payment information is released only for efforts aimed at improving the quality of healthcare services and with appropriate safeguards.”
On the other hand, healthcare hacker Fred Trotter has raised concerns about CMS’ plan to evaluate requests for the data on a case-by-case basis. That isn’t much of a policy at all, he wrote, giving federal officials too much discretion about what to release.
So, how is this all going to shake out?
Three recent examples offer some clues. Continue reading “Some Predictions on How Medicare Will Release Physician Payment Data”
Filed Under: THCB, The Business of Health Care
Tagged: AMA, Charles Ornstein, CMS, Data, Data Politics, Fred Trotter, Medicare, Physician payments, Transparency
Jan 23, 2014
I was just recently in Guiyang, the capital of the Guizhou province in China and had a chance to visit the Huaxi District People’s Hospital (HDPH), one of the largest “secondary” hospitals in the province.
Like the rest of China, it has been gripped by the construction boom, recently opening a new surgery center and revamped medical facilities. They had a terrific EHR from a local vendor — probably more sophisticated than a majority of U.S. hospitals.
Despite being in one of the poorest regions of China, the hospital has more money than it knows what to do with (so says its leadership) and is planning further expansion. The source of its wealth? A growing middle class that wants more healthcare services and has the ability to pay for it.
Background on hospitals in China
There are approximately 2853 counties in China across 33 provinces. Each county has a county hospital, a government owned facility that serves the people of that community. When the patient is too complicated to be managed there, he or she is transferred usually to a secondary hospital. Patients who need an even higher level of care are sent to the regional tertiary care hospital. The gatekeeping system is weak – one need not start at the county hospital – and in fact, a majority of the inpatients at GPH came there directly.
A few years ago, China launched a major health reform with the goal of getting to universal coverage. They got close and nearly every citizen now has health insurance that covers at least part of the costs of their care. The insurance has substantial co-pays and doesn’t cover more expensive drugs and tests. What does this mean for a hospital like HDPH? About 40% of their revenues came from insurance.
And, despite being a government hospital, only about 5% of revenues came from the government. The rest? From the patients themselves. This revenue mix is supposedly pretty typical of county and secondary hospitals across the nation. Out of pocket spending remains substantial, despite universal health insurance. In fact, in absolute dollar terms, patients are paying about as much out of pocket now as they were before social insurance kicked in.
Huaxi District People’s Hospital
Outpatient clinics, where a typical appointment might last 2-3 minutes, are by far the biggest source of admissions to the hospital. But the hospital also has an ER. Actually, two: a Medicine ER and a Surgery ER. The patient gets to choose. Unsure about which you need? There is an “Enquiry” nurse who can help. I peppered the one on duty with various clinical scenarios and was impressed with the speed and confidence with which she made decisions.
The flow is simple: you choose your ER, you register, pay the fee in cash, and go inside to wait.
Continue reading “The People’s Hospital”
Filed Under: OP-ED, THCB
Tagged: Ashish Jha, China, Costs, Hospitals, Transparency
Jan 15, 2014
Let’s recognize Healthcare.gov as the dawn of mass patient engagement – and applaud it. Before this website, patients were along for the ride. Employers choose most of the insurance benefits, hospital web portals are an afterthought, and getting anything done with an insurance company, for both doctors and patients, means a phone call and paper. Can you imagine going online to find out the actual cost and buy anything? All that changed with Healthcare.gov.
Information is valuable and not evenly distributed. The haves are immensely valuable corporations. The have nots are patients and doctors. Welcome to the world of health IT politics where the rich get richer ($20 Billion of “incentives” have caused massive health IT consolidation and a hidden health surveillance state) and the poor get frustrated (talk to an independent physician about their EHR or to a patient trying to access her own health records).
Information asymmetry drives $1 Trillion waste of our $2.7 Trillion health care cost. That waste is about $3,000 per year per citizen.
The politics of health IT policy are not left vs. right but institution vs. individual. Politicians and regulators alike are now scrambling to understand the role of health IT policy in that $3,000 annual waste per citizen.
The asymmetry that drives health IT policy is easy to understand when you consider that health IT is sold to corporations. As physicians and patients, we do not prescribe or buy information technology and we are paying the price through a total lack of price and quality transparency.
Continue reading “Information Asymmetry – The Politics of Health IT Policy”
Filed Under: Tech
Tagged: Adrian Gropper, Healthcare.gov, HIT Privacy, The ACA, Transparency
Nov 9, 2013
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”
Filed Under: Physicians
Tagged: ABIM, Bob Wachter, Center for Medicare and Medicaid Innovation, Outcomes, Patient Safety, Quality, Transparency, Value
Jul 1, 2013
I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.
“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.
It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.
That run has ended.
Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).
These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.
Continue reading “How UCSF Is Solving the Quality, Cost and Value Equation”
Filed Under: OP-ED, THCB
Tagged: Bob Wachter, Costs, Gary Kaplan, Hospitals, LEAN, Patient Safety, Quality, Transparency, UCSF, Value
May 27, 2013