Month: August 2011

Work Hour Restrictions – A Painful Gift to Medicine

Aug 25, 2011• 2

By VIPAN NIKORE, MD

When I completed my overnight shift and left the Medical ICU the morning of July 1, I raised my arms victoriously. I uttered, “Finally, internship is done!” I may have been one of the last to speak such words.

As of July 1, 2011, intern year forever changed. In the world of medicine the first year of residency, or intern year, is when doctors earn their stripes. Traditionally it is the most demanding year in a decade-long quest to become a practicing physician. But this year, the Accreditation Council of Graduate Medical Education (ACGME) mandated that interns can no longer work more than 16 hours straight, and must have 10 hours off between shifts. Second- and third-year residents can still work 28-hour shifts, but no more 30-hour shifts for interns.

To the outsider, this may seem like a common sense change that would only improve patient safety. Within the medical field, however, this change is arguably the most controversial in the history of medical education.

Advocates believe these duty-hour modifications will decrease medical errors and improve unacceptable working conditions for residents. ACGME officials still believe that residents should be able to handle the vigorous hours and workload, but believe launching the least experienced physicians — new interns — into those demanding conditions just days after medical school is inappropriate and unsafe. As well, the general public generally favors the new changes.

DC to VC Start-up Showcase

Aug 25, 2011

By Matthew Holt

This time of year is all about selection. Which demos should we have for the Health 2.0 Conference coming up next month? Who to have speak in the Health 2.0 Europe Conference in Berlin in October? How to fit in a vacation around the Health 2.0 India Conference in December? But believe it or not, Health 2.0 isn’t all there is!

Rebecca Lynn, Ching Wu, & their colleagues at Morgenthaler Ventures started DC to VC last year, and this year they’re hosting the DC to VC Start-Up Showcase during Health Innovation Week in San Francisco. It’ll be on September 22nd at the Microsoft Campus in Mountain View, CA. I’m delighted to be MCing this event, and was even more fascinated to be a (minor) part of the selection process. Rebecca really showed that it is hard to be a VC (I’m not kidding), but with great skill and lots of patience she helped us cut to the chase of the more than 125 applications and elevator pitches. There were lots of great submissions and some companies everyone loved didn’t even make the final group.

Today the finalists were announced including a class ready for seed stage (very early) and one slightly further along (ready for Series A). So drum roll please and get ready.Continue reading…

The Emperor Remains Unclothed

Aug 23, 2011• 33

By PAUL LEVY

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs. But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense. They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight: “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare. Elected officials hate being blamed for directly restricting access to medical treatments — even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology: “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals. This can happen only if we change our fee-for-service payment system.”

And What Happens if the Individual Mandate is Struck Down?

Aug 23, 2011• 4

By ROGER COLLIER

An alarming article in Politico.com looks at what could happen if the Supreme Court determines that the Affordable Care Act’s individual mandate provision is unconstitutional—something that the current conservative leaning of the Court seems to indicate is somewhat more likely than not.

Assuming that such a possible decision by the Court follows that of the Eleventh Circuit Court of Appeals in ruling that the mandate is unconstitutional but the remainder of the ACA may stand, the Politico.com article anticipates some potentially disastrous consequences.

The provisions of the ACA—some of them already in force—include guaranteed issue, elimination of annual and lifetime limits, and a ban on basing premiums on health status, essentially decoupling coverage and premiums from insurance risk. Without the requirement for almost everyone to have coverage, there will be nothing to ensure that the risk pool contains a large percentage of individuals in good health as well as those with medical problems, and nothing to stop anyone from waiting until they’re sick or injured to demand coverage.

Peter Pronovost is a Liar. He Must Be. Isn’t He?

Aug 23, 2011• 1

By PAUL LEVY

Peter Pronovost and his subversive friends are at it again. Imagine, first they assert that implementation of a standard protocol and checklist could reduce the rate of central line associated bloodstream infections.

“It wouldn’t work here. Our patients are sicker.”

Then, to make matters worse, they go and contend that reducing the rate of central line infections saves money. Here’s the abstract from the American Journal of Medical Quality:

This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover.

A Student’s Summer Reflections on Price Transparency

Aug 23, 2011

By JEFFREY HERMAN

I can’t think of a single industry that is more inherently personal—more emotional than health care.

Everyone has a story of how the health care system has impacted their lives. My family’s experience with the healthcare system had both positive and negative results. Thankfully, my brother survived a brain tumor as a young child and my father’s heart disease was treated early enough to prevent a heart attack. However, the bills for these procedures were astonishing. Perhaps even more shocking was the complete inability of doctors and insurance companies to give an accurate estimate of what the procedures would cost. There was no more clarity with routine follow-up procedures like MRIs and stress tests. On any given day, a doctor may order the same test several times, so how does uncertainty exist about how much it costs? And if doctors don’t know the cost, how are patients supposed to be informed consumers of health care?

Many insured patients don’t worry about how much a procedure costs—frankly, with third-party payers, they often don’t have to. In fact, if you are sick and diagnostic tests are covered, you might push for your doctor to administer all potentially beneficial services. However, at some point the over-utilization of services at unclear prices results in detrimental care that is ultimately more costly than helpful. In some cases, particularly for patients with high deductibles or loop holes in their insurance plans, these costs may even cause significant financial harm.

Meaningful Use Requires Meaningless Data

Aug 23, 2011• 21

By DINOSAUR, MD

Race is a medically meaningless concept.

Spare me the few tired cliches about prostate cancer, diabetes, and sarcoidosis being more common in blacks than whites, or even the slightly increased risk of ACEI cough in patients of Asian descent. We screen Jews of Ashkenazi descent for Tay Sachs without any racial labeling. All that information is readily accessible under the Family History section of the medical history. It is no more than custom which dictates the standard introductory format including age, race, and gender. It turns out I’ve blogged about this before at some length (pretty good post, actually). What is new is the advent of electronic medical records.

Much hullabaloo has been made about federal stimulus funds allocated to doctors as payments for adopting EMRs; “up to $44,000!” Here’s the problem with that figure, though, including how it breaks down (source here):

[M]aintaining [an EMR] costs multiple thousands of dollars a year. Bear in mind that they’re not talking about a lump sum payment of $44,000. It’s $18,000 the first year, $12,000 the second year, $8000 the next, $4000 the next, and then $2000, for a total of $44,000 spread over five years. FOR A SYSTEM EXPECTED TO COST AN AVERAGE OF $10,000 PER DOCTOR PER YEAR, not counting the start up costs, which run in the vicinity of $50,000. $44,000 over five years for something that will cost us $90,000 over the same period? And that’s even if they actually get around to giving out the money in the first place! According to this, in order to qualify for “meaningful use,” EMRs must be used for ePrescribing, for communicating with other EMRs like labs and hospitals, and for transmitting information on performance measures (the paternalistic proxy for “quality”) to the government.

Health Policy Schizophrenia

Aug 22, 2011• 21

By JOHN GOODMAN

The Obama administration has told us how it intends to change Medicare many times and in many places.

It wants to replace fragmented decision making by independent doctors with coordinated care delivered by doctors working in teams, connected to a medical home. It wants Medicare to purchase quality, not quantity. It wants decisions to be evidence-based. It wants electronic records in order to standardize care and reduce errors.

So how does the administration plan to get all this done? It plans to spend hundreds of millions of dollars on pilot programs to try all these ideas out and then ……

Wait a minute. Aren’t these ideas already being tried out somewhere? Yes. In Medicare, as a matter of fact. How well are they working? As a long-time critic of managed care, I admit the results look pretty good.

Decision Fatigue. For Doctors, Too?

Aug 22, 2011• 2

By PAUL LEVY

This article by John Tierney in the New York Times suggests that humans suffer from decision fatigue, the tendency to make worse decisions as you make a series of hard decisions as the day goes along. Here are some pertinent excerpts:

No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price. It’s different from ordinary physical fatigue — you’re not consciously aware of being tired — but you’re low on mental energy. The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences. The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice. Ducking a decision often creates bigger problems in the long run, but for the moment, it eases the mental strain. You start to resist any change, any potentially risky move. Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. Continue reading…

Health 2.0 Show on Big Data–12 noon PST Monday

Aug 21, 2011

Join us for the next episode of the Health 2.0 Show, airing Monday, August 22nd at 12:00 PM PST (3pm EST)–Yes that’s tomorrow or even today (depending on when you read this!!) We’ll give a preview of the 2011 Health 2.0 fall conference session, Data Drives Decisions: The New World of Analytics, Data Mining and How Big Data Will Transform Health Care.

In recent years, the world of data has evolved and researchers are able to spend less time gathering data in the traditional sense, and more time analyzing and tailoring data that fits their needs. As data is mined and dissected in new and innovative ways, it not only affects research, but health care decisions and outcomes, and ultimately, helps our current system become smarter. In addition to diving into the content, we’ll feature a few special guests and talk about some of the exciting demos we have planned. Our guests will be: