Author Archives

John Irvine

The Purpose-Driven Hospital

I was incredibly impressed by the announcement this week that three top U.S. health systems – Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan Health System – will be enforcing standards that prevent low-volume hospitals from performing certain surgeries.

This comes on the heels of a major U.S. News story which showed that patients who had surgeries at low-volume hospitals faced significantly higher risks of complications and death.

The data itself is not surprising. The relationship between low procedure volume and worse outcomes has been well documented since a first major publication on the topic in 1979.

It’s also common sense. The more times you perform a procedure, the better you will be at it. If you’re only performing a hip replacement surgery 3 times a year, chances are you won’t do it as well as a surgeon who performs 200 a year. Practice makes perfect.

Instead, what’s surprising is that these three major medical systems are putting their feet down, even though they don’t need to.

There’s no Obamacare incentive. In fact, this decision could cost these health systems a lot of revenue. And this will certainly upset some surgeons and staff who want to keep performing those surgeries.

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Value-Based Care’s Data Problem

Rachel Katz OptimizedLisa is an administrator at an Accountable Care Organization, or ACO — a new healthcare payment model that encourages coordinated, high-quality, and efficient care. Lisa’s ACO facilitates the program at about 100 clinics around California, and her mission in the first year of operating might seem elementary to an outsider: to report a set of metrics to Medicare that indicate the health of patients who had been seen at these clinics.

At the start of 2015, Lisa received a panel of patients to review. She had expected a list of about 600, but instead there were 2,400. For each, she needed to report on a specific outcome or physician practices — like which beneficiaries with hypertension had blood pressure less than 140/90 and which had been screened for a risk of falling.

The kicker: she had just six weeks to submit this data. Most of the clinics didn’t have staff to do the required reporting, so Lisa contracted an assistant to travel from clinic to clinic, collecting the information they needed. About a quarter of the clinics used paper records, so the pair of administrators leafed through stacks of paper charts for the blood pressure and screening data.

In six weeks, Lisa collected 2,400 data points from across the clinics and submitted them to a third party vendor who would produce reports for Medicare. Lisa will wait until August to find out whether the ACO met its goals.

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New York Innovates in Medicaid—But Ignores a Key Member of the Team

New York has an opportunity to make real improvements to its Medicaid program; but it is leaving out key health care providers which might be best positioned to cut costs and improve value.

The state has undertaken a $6.4 billion dollar initiative, the Delivery System Reform Incentive Payment (DSRIP) program, to reduce avoidable hospital use by 25 percent over the next 5 years. DSRIP is testing ways to do everything from cutting unnecessary emergency room visits to reducing transmission of HIV/AIDS.

This could lead to healthier, more productive lives for New York’s 6 million Medicaid beneficiaries and could generate positive spillover effects for all New Yorkers—if hospitals, physicians, and other providers adopt better ways to manage Medicaid patients, they are likely to use those improvements to assist all their patients.

A team approach, coupled with preventive health care to avoid hospitalization and appropriate follow-up care, is an important part of the strategy. Better coordination between community physicians and the hospital, and better information for patients, can save money and improve health outcomes.

The problem? New York’s DSRIP program is mainly confined to “safety net” providers,  including hospitals, academic medical centers, nursing homes, individual physicians, and others with a high volume of Medicaid or uninsured patients. The state limits the participation of physician groups known as Independent Provider Associations (IPAs) because they are not considered Medicaid providers.

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A Call For a New Accreditation Body For Health IT Privacy


As shown by breaches of personal information on innumerable individuals over the years, our approach to IT security falls short. Recent intrusions at Sony Pictures Entertainment and Anthem Health (80 million individuals) against a backdrop of substantial losses of personal health (PHI) and other IT information previously again brought this deficiency again to public attention. According to one estimate, almost 1 billion records were stolen via 1500 breaches in 2014, a 78% increase from the previous year and a clear indication of an increasing problem. Among personal information, health records are particular targets, bringing in $20 per record versus $1-$2 for a credit card and surveys consistently show considerable public concern about the privacy of PHI.

In a recent commentary, David Brailer proposed that raised security standards for health information be one of four principles underlying new privacy legislation. I strongly agree and would add a specific step to apply this principle – privacy accreditation for health data custodians.

Whether the information is stored for care, insurance or research, the public lacks understanding of the complexity of their stored PHI and the large number of individuals with access to or custodial responsibility for it. There is thus a wide gap and power differential between data providers and those who hold enormous amounts of sensitive health data. This circumstance creates a need for an empowered intermediary to act on the public’s behalf, i.e. an accreditation body.

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The Readmissions Penalty at Year Three: How Are We Doing?

Ashish JhaA few months ago, the Centers for Medicare and Medicaid Services (CMS) put out its latest year of data on the Hospital Readmissions Reduction Program (HRRP). As a quick refresher – HRRP is the program within the Affordable Care Act (ACA) that penalizes hospitals for higher than expected readmission rates. We are now three years into the program and I thought a quick summary of where we are might be in order.

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.Continue reading…

Patient Engagement: Much Bigger Than Patient Portals

Tom GuillaniThere is no doubt that the topic of patient engagement has taken center stage in healthcare. It was the hot topic at HIMSS 2015 where a major national study was unveiled, Three Perspectives of Patient Engagement. And that was just one of the many sessions, events, and booths focused on patient engagement at the event.

Thanks to Meaningful Use, a lot of the focus on patient engagement has been around patient portals. It makes sense since practices have to meet specific thresholds in both MU2 and MU3 for portal use. They certainly play a key role in providing patients with access to medical records, test results, and even tools like online scheduling and billpay. The benefits have not gone unnoticed by providers. Over 80% of doctors believe a patient portal helps with patient satisfaction and 71% believe it helps with patient/physicians communication. The benefits haven’t gone unnoticed by patients either. Two-thirds of patients say they would be more loyal to physicians who provides a portal through an EHR.

Despite the undeniable value of portals, they are just one component of true patient engagement. This was clear in the presentation about the new national study released at HIMSS. According to the presentation, the biggest problem in creating patient engagement isn’t providing access to health information. The problem is shifting the attitudes and expectations of both clinicians and patients.

Resolving this problem requires a major culture change in healthcare. Despite the fact that patients and providers say they want improved access, communication, and outcomes and that patient engagement may hold the key, change is slow.

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Forks In the Road

On Saturday, Dr. Hadler delivered the commencement address at the University of Michigan Medical School.  THCB is pleased to feature his remarks. 

Nortin HadlerThank you, Class of 2015, for the privilege of sharing this special occasion with you, your families and the community that has come together to celebrate with you. This is a rare day of pure self-indulgence. Our professional life allows little room for self-indulgence and seldom applauds when one of us makes the room. For those of you who are drawn to a career anchored at the bedside, the trade-off is the quiet, internalized quest to become the best physician you can be. I have pursued this goal nearly all my life – literally, I have been working in hospitals since I was 12. If I had it to do over, I would pursue the same goal.

This goal demands expertise. Expertise requires intellect and discipline. I have a superabundance of both and so do you. Expertise is necessary but not sufficient.  More than expertise, one must understand myriad contexts in which illness plays out.

Medicine is not a science. Medicine is a philosophy informed by science.

I was a medical student when this dawned on me. Like you, I entered clinical rotations brimming with the pathophysiology of all those diseases that are poised to smite a mighty blow. Was I missing the forest for the biochemistry? Many of our patients are elderly patient and plagued by more than one serious disease. As we set to the task of confronting each in turn, it occurred to me that I might not care as much about what kills me as I care about when, and what the journey was like? Today, we have a good handle on that “when”. I can make a strong argument that if you manage to stay well to 85, you’re off warranty.

Notions of “fatal diseases” and of “saving a life” demand a temporal component.  Realize that in America, you can’t die without a diagnosis. In the mid-1980s, I started to sign the death certificates of frail elderly patients with “It was her time.” I would get a call from Raleigh; Doctor Hadler you can’t do that. I’d respond, “Which of the several diseases vying for the honor do you want me to list?” Whenever you hear of the epidemic of cancer or heart disease or stroke, ask the “When” question.

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The “21st Century Cures” Draft Bill: A Step Away From Transparency

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There is optimism that Congress will soon pass the 21st Century Cures bill. The draft bill proposed by the House Energy and Commerce Committee aims to foster medical innovation by streamlining the FDA regulatory process and increasing NIH research funding by $10 billion. The draft bill has overwhelming bipartisan support and will benefit patients, medical researchers and pharmaceutical companies. However, it also includes a passage, which aims to amend the Sunshine Act and exempt pharmaceutical companies from reporting the payments they make to physicians for continued medical education (CME) programs. The supporters of this change argue that physicians learn about the latest developments in medical science through CME programs and that requiring the disclosure of these payments would discourage pharmaceutical companies from financially supporting educational programs. Ultimately they believe it could inhibit the diffusion of medical innovation among doctors.

I took a look at the data released by CMS on the financial transactions between the pharmaceutical companies and individual physicians. In the last five months of 2013, more than $120 million were paid to physicians who participated (as faculty or speakers) in CME programs. The payments constitute 26 percent of the total financial transactions between pharma and individual physicians. The proposed change essentially allows pharmaceutical companies to hide more than a quarter of their payments to physicians. Exempting the pharmaceutical companies from reporting the largest part of their financial relationship with doctors will not help to foster medical education, rather it will add to current suspicions about the unjustified impact of such payments on the drugs that physicians prescribe to their patients.

If CME programs legitimately increase the awareness of physicians about the latest medical innovations and provide them with unbiased information about new drugs, then both pharmaceutical companies and those physicians who serve as speakers and faculties of such programs should be extremely proud of their role as champions of innovation and envoys of the latest knowledge in the medical community. If that is the case, one would wonder why they wouldn’t embrace and support the efforts that shed light on their noble role.

Patients heavily rely on the recommendations of their doctors to make any kind of decision regarding their health and thus have the right to be informed about the possibility that their doctors have a conflict of interest. Congress should refrain from amending the Sunshine Act and avoid jeopardizing the patients’ right to have access to information.

Niam Yaraghi is a fellow at the Brookings Institute Center For Technology Innovation. His posts appear regularly on THCB and on the Brookings Institute Tech Talk blog, where this post first appeared. This post also appeared as an opinion column on the US News and World Report site.

Patient-Centered Research Can Improve Chronic Pain Care and Address Opioid Abuse

Joe SelbyFor more than a decade, the United States has faced an escalating opioid abuse crisis. The number of deaths associated with abuse of these prescription painkillers more than tripled between 1999 and 2012 and now outstrips the number associated with any other drug, according to the US Centers for Disease Control and Prevention. The problem is estimated to approach $56 billion in costs to society.

Often, opioid abuse or overuse is associated with patients seeking effective relief from the common and often devastating problem of chronic pain, which has been reported as affecting up to one in three US adults. People in pain often request opioid medications, not understanding that these drugs don’t effectively treat certain types of pain, don’t work well for many people, and can lead to a range of additional health problems.

Researchers, policy makers, clinicians, and their professional organizations are working hard to stem the opioid abuse epidemic, seeking ways to reduce overprescribing of these drugs by expanding the use of alternative and supporting therapies, as well as identifying more effective treatments for addiction.Continue reading…


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