Month: April 2013

The Extinction of the Primary Care Clinic Nurse

Apr 22, 2013• 5

By Jaan Sidorov, MD

The Passenger Pigeon. The Dodo bird. The primary care clinic nurse. All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.

Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs. “There are no ‘nurses'” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”

Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms. True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.

This columnist looked for medical literature on the topic. He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape. If he’s wrong, he wants to hear from his readers.

If true, what are the implications?
Continue reading…

How to Deliver Patient-Centered Care: Learn from Service Industries

Apr 22, 2013• 6

By Brian Powers, Amol Navathe, MD & Sachin Jain, MD

Over the past decade, patient-centered care has become a mantra for high-quality health care.

Policymakers, researchers, physician-leaders, and patients have all cited the need for care to be tailored to patients’ unique needs and preferences. And there is solid evidence that patient-centered care can help improve care quality and reduce costs. However, in the rush to become more patient-centered, the health care system has misplaced its focus.

Current approaches to patient-centered care are based on aggregated preferences rather than individualized needs. Researchers and health systems deploy focus groups and surveys to assess general patient preferences in an effort to determine “what patients want.” But patients are a diverse group with diverse needs. Characterizing general beliefs and preferences alienates those whose needs and preferences do not align with the majority. The result has been a monolithic view of patients and their needs — a framework that prevents the delivery of truly patient-centered care.

All service industries share the challenge of providing tailored, individualized service. In response, leaders in customer service have developed tools and infrastructure to understand and respond to individual needs and preferences. Health care providers should leverage these approaches.

Recently On THCB

Apr 21, 2013

Is Patient Engagement the Solution…or a Healthcare Urban Legend? (30)

By Al Lewis

If you want to repair a seriously broken healthcare system, the thinking goes, you need to get at the root of the problem. And chronic disease is one of the best places to start. Convince people to take the steps that can help prevent chronic conditions like diabetes, high blood pressure and stroke and you’re on your way to a solution. There’s only one problem with that, argues Al Lewis. It’s a lot more complicated than they told you.

An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week (31)

By Leslie Kernisan, MD

With frustrated physicians leaving primary care for higher ground in record numbers there are alarming signs that the primary care system as we know it may be about to implode. How can we encourage docs to stay in the primary care game? THCB contributor Dr. Leslie Kernisan has a controversial idea: limit the number of hours that physicians work each week.

Why Medicare Cuts Will Quietly Kill Seniors (13)

By Michael L. Millenson

Recent reports that oncologists are denying treatment to Medicare patients are probably just the tip of the iceberg, argues THCB contributing editor Michael Millenson. If past cuts are any guide, we’ll only know how bad things really are years from now, he writes. And that should be cause for real concern.

Practice Redesign Isn’t Going to Erase the Primary Care Shortage (36)

By Jeff Goldsmith

The current thinking is that new technologies, better information and a more scientific approach to the practice of medicine will let doctors do more than ever before, allowing them to leap tall buildings at a single bound, see record numbers of patients and improve their patient satisfaction scores. And that may well turn out to be true, argues the University of Virigina’s Jeff Goldsmith, but we’re still faced with a problem that is not going to go away until we come up with a solution: a shortage of living, breathing human beings with medical degrees going into primary care.

Facebook Is Bad For You-and Giving Up Using It Will Make You Happier (8)

By Akshat Rathi

Forget the post IPO-backlash, Facebook is making a comeback. Marketers are in love with the idea of building Facebook pages for their clients. Cause-based groups like Facebook’s ability to take their ideas to audiences of millions and millions of potential supporters. But what is good for – say Dunkin Donuts or Southwest airlines may not be quite as good for human beings. You obsess for hours over your Facebook profile. Rate your day on your likes. Could all of this attention to your online existence possibly be bad for you in some way?

So It Turns Out Inventing Your Own Business Model Is More Fun Than You Were Expecting… (10)

By Rob Lamberts, MD

You actually thought reinventing healthcare was going to be easy? You thought all you were going to need were some cool ideas, better technologies and supportive patients? My friend, allow us to introduce you to the cold hard brick wall of reality. A couple of things you may have neglected to consider. What happens when your cool new technology doesn’t work the way it’s supposed to? What happens when the builder calls to say they’re a month behind schedule? It turns out that reinventing your world can be surprisingly stressful. A progress report from Rob Lamberts.

Designing the Doctor of the Future (16)

By Jacob Scott, MD, Ali Ansary, & Sandeep Kishore

What will your doctor look like 50 years from now? We’re hearing some pretty futuristic answers. A robot? An algorithm? A warm and compassionate human being as capable of a group hug as coming up with a data-driven treatment plan? How can med schools and medical educators prepare students for an uncertain future? Jacob Scott, Ali Ansary, and Sandeep Kishore offer a little advice to get started.

Will Your Health Insurer Pay to Train Your Doctor? (7)

By John Schumann, MD

Should insurers, pharma companies, health IT companies and others that benefit from the system help foot the bill for training the next generation of doctors? John Schumann argues one solution might help and might even improve strained relations between industry and doctors.

Chronic Care at Walgreens: Why (Not)?(15)

By Ishani Ganguli, MD

Earlier this month Walgreens became the latest retailer to announce that it will be opening in-store clinics where consumers will be able to find services that once upon a time could only be found at their local doctors office. Critics – including your aforementioned local doctor – are wondering about the impact on care. Other analysts see a logical response to the current system’s inefficiencies that might well reduce pressure on an overworked system. Ishani Ganguli, MD walks us through the story.

Letting the Data Speak: A Fresh Look at Health Care Cost Growth (14)

By Frank de Libero

You’ve seen the chart so many times that your brain no longer even registers it when you see it. Red and blue squiggles trending to infinity. If you’ve opened a textbook or heard a presentation in the last ten years, you’ve seen the infamous health care costs growth chart. A fresh look by data statistician Frank de Libero suggests the messy red and blue squiggles on those charts we were looking at may have been misleading us.
Continue reading…

Driving Front Line Innovation In Health Care

Apr 19, 2013• 1

By David Duncan

Jennifer Stinson was a nurse at The Hospital for Sick Children (SickKids) in Toronto who enjoyed brainstorming new ideas for improving care, especially for the kids with cancer she treats. But even as she gained status by getting her PhD and becoming a clinician scientist, she came up against persistent bureaucratic and organizational barriers to innovation.

Stinson’s challenge is common at big organizations, but overcoming bureaucracy and breaking down silos is especially critical in healthcare. To tackle these obstacles at SickKids, CEO Mary Jo Haddad in 2010 elevated innovation to a “strategic direction,” and engaged Innosight to help devise a full system needed to spur innovation. The resulting system has three major components:

An Innovation blueprint detailing the types of innovations the organization wants to encourage. SickKids prioritized encouraging doctors, nurses and clinicians to look for unmet needs they could address, rather than wait for solutions from IT or top management. That required creating a focus group with 25 front-line healthcare workers to discover and catalog key “jobs to be done” (like reducing the length of hospital visits), surveying all 5,000 employees, and training most of them on how to integrate the innovation system into their daily practices.
An innovation pipeline to reliably take ideas from concept to reality. This involved establishing a new 18-member Central Innovation Group of leaders from different areas of the hospital, a team that was tasked with prioritizing and advancing ideas and projects through various stages. The team helped innovators test prototypes, make adjustments, and then scale to a wider population.
An innovation culture that features the right people, in the right roles, speaking a common language of innovation. A key enabler of this culture was the establishment of a $250,000 Innovation Fund to provide seed money for promising ideas. Now, instead of being stalled by permission hurdles that suppress initiative, promising new ideas could be funded, fast-tracked and prototyped.

Consider how the new system helped Stinson bring a transformative innovation to life. Every year at SickKids, thousands of children are battling various forms of cancer. It’s vital that they keep accurate diaries tracking their pain, but if it’s not done daily the data are virtually worthless. Typically these diaries must be filled out by hand, an annoying task that children with cancer aren’t motivated to do. The result is poor reporting and suboptimal pain management.

A Tale of Two Births

Apr 19, 2013• 48

By David Overton

I have two sons, both healthy happy boys, both brought into this world in very different ways. I work in healthcare and like many readers of THCB, the business of healthcare is often viewed through the business lens. When we become the healthcare consumer, and are knee deep in the conundrum that is our healthcare system, the perspective changes dramatically.

Ezra was born in a major medical center, under the supervison of state of the art OB/GYNs, with all of the greatest technology, and under the care of the best nurses. My wife wanted a “natural birth”, so natural that I affectionately describe it as a “granola birth”. We were active duty military at the time so our choices were limited. She hired a birth doula, read Ina May’s “Guide to Childbirth”, chose to see a Women’s Health Nurse Practitioner for her wellness visits, and was adamant that she did not want an epidural.

As we approached 40 weeks the adventure began. At 36 weeks she could no longer see the NP, she had to now see the OB/GYN. The OB/GYN began to make reference to not allowing us to go past 40 weeks, it would “endanger the child”. My wife began to feel very uncomfortable and that she was slowly losing control of the experience she wanted to have. At the 40 week visit, the OB/GYN gave a very stern warning that an “induction was now necessary for the safety of the baby” regardless of there being no indication that Ezra’s wellbeing was compromised. We resisted as much as possible (with the help of no beds in the maternity ward) but at 41 weeks and 2 days, doctors’ orders brought us into the hospital for an induction.

The Affordable Care Act: Like It Or Not, It’s Catalyzing a Golden Age In Health Care Investing

Apr 18, 2013• 4

By Al Waxman

Now that President Obama has been re-elected and the Supreme Court has upheld the Accountable Care Act, healthcare reform is here to stay. So what does reform mean for healthcare investors? I believe it will usher in a new fertile period for innovative,venture‐backed companies that can navigate the brave new world of healthcare delivery and management.

The Accountable Care Act impact on healthcare IT investing is already being felt.Venture investment in 2013 is showing significant growth from last year. In 2012,according to PWC, a global accounting firm,the life sciences sector which includes healthcare IT accounted for 25 percent of all venture capital dollars invested which totaled nearly $1.2 billion in 163 deals,more than double the $480 million in 49 deals in 2011 and almost six‐times the $211 million in 22 deals in 2010.

Now is the time to make order out of chaos and to set the stage for a next‐generation healthcare system that can effectively service our nation. At Psilos Group, we have just released our fifth Healthcare Economics and Innovation Outlook and identified the following four areas as the most promising opportunities for healthcare investors in 2013 and beyond: Private health exchanges, consumer‐focused insurance programs, 21st century healthcare technologies, and innovations that reduce error and waste.

Investing In Exchanges

The healthcare insurance marketplace—and the way insurance is bought and sold—is facing massive change.Healthcare insurance exchanges, both public and private,promise to create a more organized and competitive market for buying healthcare insurance, which could moderate price increases that are currently spiraling out of control.

From our perspective, exchanges are an intelligent place to invest. Software and services will power the exchanges. Psilos envisions massive opportunities for technologies that enable operators of both public and private exchanges to build high functioning platforms, including the shopping software and back‐end administrative technology and service products needed to serve tens of millions of people efficiently.

Why Surgical Complications May Actually Hurt Profits Despite What You’ve Just Read

Apr 17, 2013• 4

By Eli Perencevich, MD

There’s a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and came to the conclusion that admissions that include a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors conclude that this creates a disincentive for hospitals preventing surgical complications since they might see reduced profits as a result. This is a very provocative finding and it’s getting a lot of well-placed media attention, as you might expect. There is an important caveat with the study that I would like to highlight.

In the study, the authors report that admissions with surgical complications result in $39,000 higher “profits” if the care is reimbursed via a private payer and $1800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial,

“Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services.“

His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a US hospital.

Finalists in the Shire ADHD Transitions Challenge

Apr 17, 2013• 2

By Graeme Ossey

We are excited to announce the finalists of the Shire ADHD Transitions Challenges! The five finalists submitted innovative ideas for web or mobile apps that will help young adults, who are entering college or the workforce, manage their medication and help them conquer daily organizational and life management challenges. Let’s meet the finalists!

The ActionsHero App works the way that the ADHD brain works best; fast-paced, fun and with instant rewards. It takes time management to the next level in an integrative, fun way that keeps people actively involved on a daily basis and moving forward in small steps. Breaking down tasks into 8 areas of life helps maintain important priorities and gives the balanced outlook often missing in schedule planning.

ADHDGo will provide developmentally appropriate help to young people with ADHD through social support opportunities, practical life skills, expert information and self-management tools as they transition from adolescence through college and ultimately to the working world. The product utilizes a single convenient mobile website that is available anywhere at any time via desktop, laptop, smartphone or tablet.

GenR Media has created the Life Balance Zone – College Life app. The app contains 4 main zones that are designed to support the student throughout their time in college – Planning Zone, Study Zone, Resource Zone, Reward Zone. Features like required study time and morning check-ins are built in the app to help the student balance their life in college and stay on track and reward him/her extra study breaks, playing a brain game featured in the app, or using small reward gift cards given by friends or family.

The Arkansas Experiment: Is the ‘Private Option’ a Realistic Plan For Medicaid?

Apr 17, 2013• 1

By Naomi Freundlich

Arkansas is now the first state to use Medicaid expansion dollars to buy private coverage for many of its 250,000 newly eligible residents rather than enroll them in the existing Medicaid program. This week the Arkansas House of Representatives approved the plan, followed by the Senate, to confirm that the state will be implementing this “market-based approach” to expanding Medicaid.

The idea of buying private insurance for Medicaid recipients is emerging as a “conservative compromise” for some of the 24 states (home to more than 25 million uninsured residents) leaning toward rejecting federal funding the Affordable Care Act provides for the expansion. In the original legislation, the ACA required states to expand Medicaid to adults earning up to 138 percent of the federal poverty level, $15,870 for an individual or $32,499 for a family of four. The federal government would fully cover the costs of this expansion for two years, with states gradually having to contribute 10% by 2020. Last summer, the Supreme Court struck down the Medicaid expansion requirement, allowing states to refuse federal funding and opt out of the expansion.

But most of these states, including Florida, Texas and Indiana, are leaving a lot of money on the table—from hundreds of millions to $1 billion or more in federal funding. Under pressure from healthcare providers and other interested parties, some governors view premium assistance programs that move the poor, disabled and frail elderly to the state insurance exchanges to buy private insurance as a way to capture this windfall without appearing to embrace ObamaCare.

In Missouri, for example, Republican state legislator Jay Barnes calls the Obama administration’s plan for Medicaid expansion a “one-size-fits-all, far-left-wing ideological path.”

Will Your Health Insurer Pay to Train Your Doctor?

Apr 16, 2013• 8

By John Schumann, MD

Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.

Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.

The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.

A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.

This has medical educators very worried that we will have to do more with much less (disclosure: I am one).