Year: 2014

What Makes a Good Doctor? And Can We Measure It?

Mar 22, 2014• 40

By Ashish Jha, MD

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change.

We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay. But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.

Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:

Over 200 answers came rolling in.
Continue reading…

TED2014: Grandmother Avatar with TB Beckons Medical Education Her Way

Mar 21, 2014• 6

By Michael Painter, MD

Why should I be in the same room with these people?

That’s one of the many smart questions participants posed at a Stanford Medical School meeting I attended last weekend. If I had been daydreaming (I’d never do that), I might have thought the question was for me. You see, the participants were a handpicked set of national medical education experts, folks nominally from the status quo medical-education-industrial complex—the very thing we’re trying to change.

You might think that they embodied that dreaded status quo. I’m happy to report they did not—not even close. I’m also relieved to tell you that the question (in spite of my paranoia) wasn’t for me. Instead, it was one of many challenges these thoughtful, passionate teachers tossed at each other.

“Why are we in the room?” was a challenge to each other. Why and when should teachers be in the same room with the learners?

When you think about it, that’s actually a central question if you’re attempting to use online education to flip the medical education experience. It’s also a brave one if you’re a teacher: justify the time you spend with your students.

Meet Propeller Health: Digital Health’s Poster Child for Invalid Savings Reporting

Mar 21, 2014• 26

By AL LEWIS and VIK KHANNA

We’ve seen shorter abstracts, and we’ve seen abstracts with more curious findings, but we’ve never seen a shorter abstract with more curious findings than this one, done by Dignity Health and Dr. Rajan Merchant, and financed by the California Healthcare Foundation, evaluating a gadget made by Propeller Health.

The study group’s use of inpatient care for asthma declined by a whopping 62% vs. the control group. You might think this result violates Dr. John Ioannidis’ well-known conclusion that large treatment effects are usually wrong, but you’d be mistaken. You see, there was no treatment here.

There was only an effect. Dr. Ioannidis’ result applies only to actual comparisons of effects due to different treatments, not to random changes in effects using the same treatment. In this study, the actual treatment protocol was the same and the inhalers were the same.

The only thing different was frequency of drug use. Whereas the conventional wisdom for disease management states that hospitalizations can be avoided by more adherence and hence more drug use, in this case the study group used less medication than the control group, reaching for their rescue inhalers 25% less– once every 6.3 days vs. every 4.7 days for the control group.

McNutt-Hadler Credo for Value-Laden Medical Decision Making

Mar 21, 2014• 25

By ROBERT McNUTT, MD and NORTIN HADLER, MD

Robert McNutt and Nortin Hadler respond to med student Karan Chhabra’s original post, “Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.

Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.

However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.

Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):

1) . The Death Rate is One per Person

2) . Never Poke a Skunk

3) . There has Never been a Quack without a Theory

4) . Institutions Die; People Live

Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:

1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.

2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.

3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)

Can I Record My Conversation with My Insurance Company?

Mar 20, 2014• 10

By THCBist

A THCB reader in San Diego writes:

I am SERIOUSLY annoyed. I just got off the phone with my insurer. I’d called a day ago and spoken to a representative (who was very helpful) about a claim. I called back today to follow up and check on a detail.

It quickly became obvious that something was very wrong. I realized immediately what had happened. She’d made a mistake. And left out a minor but important detail on my claim.

But instead of owning up to it, the woman pretended as though nothing had happened. It was like we’d never met before. After a five minute conversation she accused me of lying. I could not believe what I was hearing. I was outraged. I asked to be transferred to a supervisor.

The super listened to me for a minute and then took the side of her employee. “Why should I believe you? Can you prove it?”

Can I prove it? I’ve been a good customer for years. I shouldn’t have to prove it!!! “ How can I stop this from happening? Can I record my conversation with my insurer? After all, they’re recording me for “quality purposes”!!!

Lost in the health care maze? Having trouble with your health Insurance? Confused about your treatment options? Email your questions to THCB’s editors. We’ll run the good ones as posts.

Republicans Considering Proposing High-Risk Pools: Health Insurance Ghettos???

Mar 20, 2014• 2

By Robert Laszewski

We are hearing that Republicans are considering proposing high-risk pools as part of an alternative health insurance reform proposal to Obamacare.

A high-risk pool proposal would likely mean the Congress giving states the flexibility, and perhaps funding, to set up these risk pools. Risk pools by definition are a place where people can go when they are not able to buy health insurance in the regular market because they have a health problem.

That means Republicans would be turning the clock back to a time when insurance companies could turn people down for health insurance because of their health status.

Presumably, the Republicans are contemplating a market where insurance companies could once again choose just who they wanted to cover––the healthy but not the sick.

Anyone turned down could then go the high-risk pool to be assured of having health insurance. Presumably, Republicans would assure consumers that they would be able to access the same kind of comprehensive health insurance and at the same market rates as those able to buy from insurance companies would be able to get.

Let me be clear at this point that I don’t know of anyone in the insurance industry asking to go back to the days when a carrier could exclude people as a result of their health status and make money just covering the healthy.

Whether it’s Obamacare or a risk pool concept, policymakers are faced with the same dilemma: How do you insinuate the unhealthy and otherwise uninsurable into a health insurance system in a way that benefits are comprehensive and costs are affordable for everyone?

The Oncologist’s List

Mar 19, 2014• 1

By James Salwitz, MD

Lists guide our lives. Some are easy, even fun, like a menu or shopping list. Some are simple tick-offs for work, like my wife’s honey-do list. Others are frightening, like a draft list.

Some are melancholy, such as the inventory in a Will. We are inspired by our bucket-list. Finally, some are exciting, but stir conflict, like awedding invitation list.

I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up. That is my patient’s list of daily X-ray reports.

Our Electronic Medical Record (EMR), as based around a home page or “Inbox.” This is a continuously updated assembly of data and messages from our practice and patients.

There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.

Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me. Not so the eighth list, just four from the bottom: Radiology Documents.

These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients. Every 24 hours, between 15 and 30 new reports pop-up.

Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.

One click on each line yields a neat, formatted, typed report. These are more than just data. More than simple facts. These are final, cold, hard answers to the biggest questions of all.

Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs? Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?

Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?

Very Big Data

Mar 19, 2014• 9

By DWIGHT MCNEILL

The field of analytics has fallen into a few big holes lately that represent both its promise and its peril. These holes pertain to privacy, policy, and predictions.

Policy. 2.2/7. The biggest analytics project in recent history is the $6 billion federal investment in the health exchanges. The goals of the health exchanges are to enroll people in the health insurance plans of their choice, determine insurance subsidies for individuals, and inform insurance companies so that they could issue policies and bills.

The project touches on all the requisites of analytics including big data collection, multiple sources, integration, embedded algorithms, real time reporting, and state of the art software and hardware. As everyone knows, the implementation was a terrible failure.

The CBO’s conservative estimate was that 7 million individuals would enroll in the exchanges. Only 2.2 million did so by the end of 2013. (This does not include Medicaid enrollment which had its own projections.) The big federal vendor, CGI, is being blamed for the mess.

Note that CGI was also the vendor for the Commonwealth of Massachusetts which had the worst performance of all states in meeting enrollment numbers despite its long head start as the Romney reform state and its groundbreaking exchange called the Connector. New analytics vendors, including Accenture and Optum, have been brought in for the rescue.

Was it really a result of bad software, hardware, and coding? Was it that the design to enroll and determine subsidies had “complexity built-in” because of the legislation that cobbled together existing cumbersome systems, e.g. private health insurance systems? Was it because of the incessant politics of repeal that distracted policy implementation? Yes, all of the above.

The big “hole”, in my view, was the lack of communications between the policy makers (the business) and the technology people. The technologists complained that the business could not make decisions and provide clear guidance. The business expected the technology companies to know all about the complicated analytics and get the job done, on time.

This ensuing rift where each group did not know how to talk with the other is recognized as a critical failure point. In fact, those who are stepping into the rescue role have emphasized that there will be management status checks daily “at 9 AM and 5 PM” to bring people together, know the plan, manage the project, stay focused, and solve problems.

Walking around the hole will require a better understanding as to why the business and the technology folks do not communicate well and to recognize that soft people skills can avert hard technical catastrophes.

The Apple Has Landed

Mar 19, 2014• 2

By Dan Diamond

Apple transformed portable music players. It redefined what we expect from cell phones. It brought tablet computing to the masses.

Is the company planning to do the same for mobile health?

Some industry watchers think so.

This isn’t a small venture. Apple executives suggest that Healthbook is being positioned as perhaps the key selling point when the company releases its next operating system for iPhone, likely later this year. And the app also may pair with a new “iWatch” that’s under development and will contain biometric sensors.

In his lengthy post, Gurman further details how Healthbook is expected to work. Its interface is “largely inspired” by an existing iPhone application called Passbook, which is intended to centralize a user’s boarding passes, loyalty coupons, and so on in one place. Beyond fitness and diet, the app also has sections devoted to tracking physical activity, our sleeping habits, and hydration.

And Healthbook will offer blood monitoring features—”perhaps the most unique and important elements of the application,” Gurman writes—although it’s unclear exactly what it will track beyond oxygen saturation and glucose levels.

App’s appearance not unexpected

The long-awaited screenshots of Healthbook follow months of reports that Apple’s readying a push into the health care space. While the company’s interest in the sector is nothing new—my team has spent years covering its health-related innovations—Apple’s recent focus has been much more discrete.

Why the Subsidy Gap Isn’t Actually a Gap

Mar 19, 2014• 5

By Janet Weiner

A 26-year-old man who makes $36,000 a year in Philadelphia finds out that he is not eligible for a health insurance subsidy, and must pay his $205 monthly premium without any help.

This, despite the ACA’s subsidies for people earning up to 400% of poverty (about $46,000).

Has he fallen into the subsidy gap?

The latest talk about a subsidy gap into which some millennials are falling is mystifying to me. It seems to be a product of a misunderstanding about how the subsidies are calculated.

Let’s remember that the goal of the subsidies is to ensure that people earning between 100% and 400% of the federal poverty level (FPL) pay no more than a certain percentage of income on health insurance premiums.

This cap is set on a sliding scale, so that people on the higher end of the FPL scale are expected to pay a higher percentage.

The caps range from 2% for someone at poverty level up to 9.5% for someone earning between 300-400% of poverty level. That’s how the Affordable Care Act defines “affordable.”

The amount of subsidy is based on the difference between that cap and the premiums for the second-cheapest silver plan on the market. The subsidies are not an entitlement for all people earning 100%-400% of FPL, nor should they be.

They kick in only when the premium for that silver plan exceeds the stated percentage of income.

Below that cap, the premiums are considered affordable and people are not eligible for subsidies. That’s not a gap; that’s the way the law is designed.