Month: April 2014

Stop the War on the Emergency Room!!! (Fix the System Failure)

Apr 21, 2014• 13

By Nick Dawson

There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows.

What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have.

It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…

Some history

The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

Advancing Health Equity in the Digital Age

Apr 20, 2014• 17

By Karen DeSalvo, MD & J. Nadine Gracia, MD

During National Minority Health Month, we acknowledge the potential for health information technology (health IT) – from electronic and personal health records to online communities to mobile applications – to transform health care and improve the health of racial and ethnic minorities.

Lack of access to quality, preventive health care, cultural and linguistic barriers, and limited patient-provider communication are factors that aggravate health disparities.

By increasing our investment in health IT policies and standards, we can help improve the quality of health care delivery and make it easier for patients and providers to communicate with each other – a huge step toward addressing the persistence of health disparities.

The Pew Research Center’s Internet & American Life Project found in 2012 that African Americans and Latinos are more likely to own a mobile phone than whites and outpace whites in mobile app use, using their phones for a wider range of activities.

The study showed that African Americans and Latinos use their mobile phones more often to look for health information online. This has very important implications for personal management of health and interaction with the health care system.

However, barriers to widespread adoption of health IT remain.

For example, a 2014 consumer engagement report found that minorities were less likely to adopt online patient portals to access their health information than were non-Hispanic whites.

Health Information Technology: Sorry, There’s No Turning Back!

Apr 20, 2014• 13

By Paul Keckley

The American Recovery and Reinvestment Act of 2009 (ARRA), sometimes called the Stimulus Act, was an $831 billion economic stimulus package enacted by the 111th Congress in February 2009 and signed into law on February 17, 2009 by the President.

It included $22 billion as incentives to encourage adoption of certified electronic medical records in hospitals and medical practices. The rationale behind the policy directive was clear: system-wide implementation of electronic medical records enables improvement in diagnostics and treatment coordination, fewer errors, and better coordination of patient care by teams of providers.

Almost immediately, the medical community cried foul.

Their primary beef: the cost to implement these new systems would not be recovered by the incentives.

Similarly, physicians pushed back on the conversion of the U.S. coding system from ICD-9 to ICD-10. They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.

That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.

Last week, physicians won a battle: the Centers for Medicaid and Medicare Services (CMS) announced it was delaying the deadline for implementation of ICD-10 for a year, to October 1, 2015.

Why Are There so Many ___________s in Medicine??

Apr 19, 2014• 9

By ROBERT I. SUTTON

An article containing some ideas from The No Asshole Rule appeared in The McKinsey Quarterly some time ago and was summarized in The Economist.

This post is motivated by the question with which The Economist ends its little story: “If jerks cost firms so dearly, why are so many them employed?”

I think that it is a good question, and one that I have puzzled over a lot. To their point:

A study of American workers released in March found that 44 percent of Americans reported they have worked for an abusive boss. This study was conducted by the Reed Group for the Employment Law Alliance.

They surveyed a representative sample of 1,000 American adults within the past two weeks, which resulted in interviews with 534 workers.

Things are even worse in some occupations, notably medicine. A longitudinal study of nearly 3,000 medical students from 16 medical schools was just published in The British Medical Journal. Erica Frank and her colleagues at the Emory Medical School found that 42 percent of seniors reported being harassed by fellow students, professors, physicians, or patients; 84 percent reported they had been belittled and 40 percent reported being both harassed and belittled.

The full report is here. Similarly, a 2003 study of 461 nurses published in the journal of Orthopaedic Nursing found that 91 percent had experienced verbal abuse in the past month. Physicians were the most frequent source of such nastiness, but it also came from patients and their families, fellow nurses, and supervisors.

The No Asshole Rule suggests a few reasons why there are so many.

1. In our society, we value winners so much that, even if they are jerks, we tolerate, or even glorify, them because — so long as they keep making money or winning games — we think they are worth the trouble. Exhibit one is Coach Bob Knight and his long tenure at Indiana University. The administration didn’t have the courage to get rid of him because he won so many games, despite a history of atrocious behavior.

See this story and the associated 1997 video clip: It sure looks to me like he is choking the player. Knight brags that he “did it my way,” but I don’t want people doing things that way in my organization, no matter how great they “perform.”

Is Higher Spending Truly Wasteful?

Apr 18, 2014• 5

By DAVID DRANOVE & CRAIG GARTHWAITE

Two weeks ago, the Kellogg School of Management was privileged to host Joe Doyle, an outstanding economist from MIT.

In a broad research portfolio, Joe has focused on the effects from differing intensity of medical treatments.

This research is shattering some long held beliefs about the relationship between health spending and outcomes.

We think that Joe’s work is not known widely enough outside of the academic community, so we are using our blog to let you know what you have been missing and, in the process, perhaps change the way you think about healthcare spending.

It is well known that the U.S. far outspends other nations on healthcare, yet the outcomes for Americans (in terms of coarse aggregate measures such as life expectancy, infant mortality, and other dimensions) are quite average.

Of course, these outcomes are not the only things that we value in health care.

A lot of our spending is on drugs and medical services that improve our quality of life and won’t show up in these aggregate outcomes. For example, more effective pain management can decrease pain and improve quality of life – often with important economic benefits.

Despite this fact, most health policy analysts have concluded that we can cut back on health spending, without harming quality on any dimension.

This is not a new idea, of course. In a famous 1978 New England Journal article, Alain Enthoven coined the term “flat of the curve medicine” to describe how the U.S. had reached the point of diminishing returns in health spending. And for nearly 30 years the Dartmouth Atlas has documented how health spending dramatically varies across communities without any apparent correlation with outcomes.

The question has always been, what health spending to cut? Garthwaite’s previous work has shown that broad regulations requiring longer hospital stays for new mothers and their babies have provided only limited benefits and that more targeted rules could save money without sacrificing quality.

Beyond some wasteful regulations, we can always point to gross examples of overspending such as the rapid proliferation of proton beam treatments. But beyond those clear examples how can one identify what is waste and what is medically necessary?

In two important papers, Joe Doyle and co-authors ask a more fundamental question – is the often cited broad variation in health spending actually wasteful at all? They find that even in healthcare, there really is no such thing as a free lunch.

His work should be mandatory reading for everyone who believes that broad spending cuts will have no adverse consequences.

For those who lack the time to read these papers, we provide the “Cliff’s Notes” versions.

A New Way to Explore and Comment on Doctor Data

Apr 18, 2014• 2

By Fred Trotter

The American Medical Association (AMA) says the number one issue with recent data releases from HHS is that “there is currently no mechanism for physicians and other providers to review and correct their information.”

We think we have a way to fix that problem over at the DocGraph project!

Over the last two years there have been three major breakthroughs in the analysis of doctors using Open Data. The first was the original teaming and referral database obtained by DocGraph (us) under a FOIA request. The second was the prescribing data set obtained by ProPublica. Both DocGraph and Propublica worked around the 1978 injunction limiting the use of FOIA for doctor data.

The third is the new procedure pattern data set announced as the direct result of the overturning of the 1978 injunction.

We are happy to announce the release of the first “all-in-one” open doctor data browser that we are calling DocGraph Omni. We have created a public tool that allows you to browse the merger of all three major new open data sets about doctors and other healthcare providers that bill Medicare.

Now in one place you can view how a provider prescribes, how they collaborate, and which procedures they work with. Our intention to turn Omni into a browser where you can find any open data about doctors, no matter what the source.

But this is not just about “finding” the data. We have created a system that allows anyone to comment on any given data point in these data sets.

How Should Doctors Get Paid? Hourly Wage, Piecework or Quality?

Apr 17, 2014• 18

By Hans Duvefelt, MD

A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.

In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.

After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”.

But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

Things That Make Me Worry About My Colonoscopy

Apr 17, 2014• 17

By Mark Graban

Sorry to get all Katie Couric on you, but I’m going to have a colonoscopy on Friday. I turned 40 last October and I have some family history that leads my doctor to get one done now rather than at 50.

Unlike Katie, I won’t be broadcasting mine live, but I’ll share some articles and reflections on the process and, being process focused, what could go wrong. It’s a very necessary procedure, but there are, sadly, some very unnecessary and preventable risks.

According to Dr. Wikipedia (backed by journals):

This procedure has a low (0.35%) risk of serious complications

That’s about 1 in 300 patients, put another way.

For those of you who speak Six Sigma, that’s a 99.65% first time yield and a 4.2 sigma level.

That’s not going to scare me away.

Maybe I should have asked what my physician’s complication rates are. What are the complication rates at the surgical center where this will be done? Is this safer than being at a full-blown hospital or doesn’t it matter? Should I be more of an “engaged patient?”

Should I have asked more questions of my primary care provider? Why did she refer me to this GI specialist? Is he a “Best” doctor? Does that matter?

If I treat them as a supplier (respectfully), should I be able to walk the process and see what they do to prevent, say, instrument or scope disinfection errors?

Should I have asked:

Show me how you disinfect the equipment
Show me your training records for the people doing this work
Show me your equipment maintenance records
How do you verify that the work is being done properly?
Have you had any complaints or incidents in the past?

I had my pre-procedure phone call on Monday. Maybe I should follow up and ask a few of these questions, even if I can’t go “walk the gemba” to check things out myself. What would you do?

Of course, I didn’t have data or information available to me to know:

Which specialist is best at this?
Who has the highest or lowest complication rates?
What are the prices for different doctors or locations?

I don’t know how a busy person makes an informed decision.

Amazon Shows the Way on Wellness — Treat People like Adults

Apr 16, 2014• 31

By VIK KHANNA and AL LEWIS

Since 2000, the government and healthcare industry have sold Americans a bill of goods called workplace wellness, which turns out to have been a colossal waste of billions of dollars.

Most of this money was spent bribing employees to do things that they don’t want to do, such as submit to biometrics, answer intrusive health risk appraisals, and get preventive medical care.

The marketing pitch that wellness makes people healthier and lowers medical care costs, and thus, produces a return on investment for the employer, isn’t true. Wellness also allowed companies to position themselves as employee-friendly, even while wages stagnated and employees morphed into fungible widgets, instead of vital assets in whom employers invested for years or decades.

However, it looks to us as though at least one major US company is treating economic reality seriously, and, consequently, asking its employees to act like adults.

Let’s look at wellness by Amazon.com, which has apparently avoided conventional wellness whole cloth. Despite our best research efforts, we find no evidence that the company makes conventional wellness programming a priority for employees.

It’s a bit ironic that they don’t given the recent spate of tough publicity about the company’s employment practices.

Amazon has been lambasted lately for the plight of the warehouse workers who animate its backroom operation, where constant video surveillance, productivity demands, and getting your bag searched before you go home are the norms. Message boards also detail the pressure-cooker atmosphere of the company’s white collar space, which raises, in our minds, the pointed question of why haven’t they done wellness?

We think it’s because Amazon’s philosophy about work is straightforward: if you work here, expectations are high and relentless. Amazon’s approach to employee well-being seems to be to not have one other than we invite you to grow with us. This is counter-cultural, and it has more to recommend it than first appears obvious.

When you are competing against Walmart and Target, remaining lean and low-cost is critical; wellness drives costs up, not down.

Expecting many staff to work 50, 60, or even 70 hours per week leaves little time for discretionary visits to the doctor that are pointless even before they happen because this superfluous care will save neither lives nor money. When you are not pouring money into coercing employees to join a wellness program, you preserve capital needed to optimize the technologies and product mix that help you grab market share and crush competitors like Best Buy.

Whose Cancer Is It, Anyway?

Apr 16, 2014• 19

By “Knot Telling”

I recently read a blog by Dr. Danielle Ofri in the New York Times “Well” blog about how as a physician she learned to respect the patient’s wishes even when they contradict her professional inclinations. It’s called Doctor Priorities vs Patient Priorities.”

She writes that the patient is looking through a “wide-angle lens” that takes in the whole of his life while the doctor’s lens is “narrowly focused on the disease that pose[s] the gravest and most immediate risk”. She saw her challenge as entering into dialogue with her patient in order better to understand the wider perspective of his whole life and to work with him to find the most acceptable way to deal with his disease.

If only Dr. Ofri were an oncologist. If only she were my oncologist. My last appointment with my onco, Dr. G, was a disaster. Not only have I not been back to her, I have not gone to any oncologist since then. Part of that is because I don’t want any treatment at this time; that’s still true.

But if I am going to be very honest, and I try to be that always, it is also because of that disastrous appointment with Dr. G.

First of all, she would not respect my decision not to have any more chemo and refused to order any scans unless I would a priori agree to chemo if she decided it was indicated. She also mocked me. It took a long time for me to tell that second bit. In fact, from that day in August 2013 until just recently—seven months!—I only told one or two other people about what happened.

The evening of that last appointment, Dr. G called me at home to continue the argument. I found myself apologizing for causing her distress. Yes, I know that’s ridiculous, but that is how I react to being bullied. Borrowing the words of a friend who really gets it, I apologize to others for their hurtful behavior and then I internalize it. I haven’t talked about Dr. G mocking me because I feel ashamed.