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What If Success Sucks?

Nov 27, 2012• 15

By Rob Lamberts, MD

“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees. I pay him to give me the stark reality of things, but his optimism made me uncomfortable. ”You’ve got to go for this. I know you don’t feel ready for it yet, but this could really be huge for your business, and I don’t think you should pass this up.”

I sighed. Yes, this is a victory of sorts (still only theory, not reality), but what if I can’t deliver? What if I fail?

“You know,” a colleague told me during another phone conversation, “you are the buzz of the medical community right now. We talked about you for half an hour at lunch today…and it was all good!” He went on to use phrases like “our only hope,” and “the way out,” to describe the potential for my practice model.

“No,” I thought, “I am not Obi-Wan. I’m not your only hope.” I sighed. I don’t want that kind of pressure on me before I even see my first patient. What if I fail?

Even worse: what if I succeed?

One of the main things that separates good clinicians from the rest is the ability to think through contingencies. When I order a test or prescribe a treatment I have to consider the possible outcomes: if the test shows X, then we do Y; if it shows not-X, then we do Z. Or, here’s the plan if you get better on the medication, and here’s the plan if you don’t. The more contingencies I can anticipate and plan for, the more direct the path to the ultimate destination: resolution (or management) of the problem. I find that my experience in thinking through contingencies serves me well in my current job of building a new and innovative practice.

Innovation Case Studies: Small Hospital Venture Funds

Nov 26, 2012

By Dave Chase

Healthcare providers are finding their “play it safe” culture isn’t conducive to breakthrough innovation.

Facing the inevitable deflationary pressures being put upon the healthcare system, innovation is critically needed. Having spoken with several innovation groups in health systems, most examples of “innovation” are decidedly uninspiring. Primarily, it is due to the fact that virtually all of their decisions have to go through the prism of how new ideas will fit with current businesses — a guarantee that will doom so-called innovation to be little more than incremental improvements. Consequently, increasing numbers of hospitals and health systems are smartly allocating money to venture funds that have free reign to find truly disruptive new businesses.

Health systems have taken various approaches such as becoming a Limited Partner in venture funds like Health Enterprise Partners. Some of the larger systems, such as HCA and Dignity Health, have their own venture arms. A new development is a much smaller organization establishing their own venture fund. Implicit in this approach is a much more hands-on approach than as an investor in a 3rd party venture fund. Rex Health Ventures is an early example of venture-capital investment funds in the country started by a community, nonprofit hospital (Rex Health Care). The fund is being launched with an initial $10 million investment from Rex Healthcare and will help finance the most promising innovations among new medical services, tools and technologies.

Health Care Reform Gangnam Style

Nov 25, 2012• 21

By Lisa Suennen

So I read an article the other day about a new company called Rap Genius. The company consists primarily of a website that relies on crowdsourcing to explain rap lyrics to the masses who are not down with the urban vibe (aka, people over 30). The company takes lyrics such as these from Kanye West’s Gold Digger….

“She was supposed to buy your shorty Tyco with your money
She went to the doctor got lipo with your money
She walking around looking like Michael with your money.”

…and explains that they mean, to wit: The ex-wife was supposed to buy your baby some toys with the child support money but instead spent it all on so much plastic surgery that she looks like Michael Jackson (presumably before he died―my edit).

Here’s another example: Nelly’s song Grillz gets explained thusly: “Got 30 down at the bottom, 30 more at the top, all invisible set in little ice cube blocks” refers to the fact that Nelly is wearing “grillz” aka jewelry worn over the teeth, which are worth $30,000 on the top and another $30,000 on the bottom, with diamonds set right into the gold. So now you know.

According to the article about the $15m investment that venture fund Andreesen Horowitz put into Rap Genius, the company’s goal is to “annotate the Internet” and, beyond rap music, “the company is slowly spreading to other categories such as literature, political speeches, and science papers.” Let me just digress for a moment and say that the website I would love to see is the one that turns political speeches into rap lyrics―wouldn’t it be sublime to see Joe Biden and Paul Ryan speak jive?

Pay for Performance in Healthcare: Do We Need Less, More, or Different?

Nov 25, 2012• 4

By Bob Wachter, MD

The debate over pay for performance in healthcare gets progressively more interesting, and confusing. And, with Medicare’s recent launch of its value-based purchasing and readmission penalty programs, the debate is no longer theoretical.

Just in the past several months, we’ve seen studies showing that pay for performance works, and others showing that it doesn’t. We’ve heard from some theorists who describe P4P as sapping intrinsic motivation and doing violence to professionalism, and others who feel that its effects are as natural and predictable as water running downhill. Some commentators beg us to stop it, while others denounce P4P’s current incarnations as too wimpy to work and recommend they be turbo-charged.

If we weren’t talking about the central policy question of a field as important as healthcare, we could call this a draw and move on. But the stakes are too high, so it’s worth taking a moment to review what we know.

In the U.S., the main test of P4P has been Medicare’s Hospital Quality Incentive Demonstration (HQID) program. A recent analysis of this program, which offered relatively small performance-based bonuses to a sample of 252 hospitals in the large Premier network, found that, after 6 years, hospitals in the intervention group had no better outcomes than those (3363 hospitals) in the control arm. Prior papers from the HQID demonstrated mild improvements in adherence to some process measures, but – as in a disconcerting number of studies – this did not translate into meaningful improvements in hard outcomes such as mortality.

Is It Time To Charge Medicaid Members for ER Usage?

Nov 24, 2012• 62

By Al Lewis

No one would deny that we’ve reached a point in public healthcare finance where tough choices have to be made about what gets covered and what doesn’t. There is, however, one fairly easy choice, and that is to reconfigure the $3 copay for Medicaid members using the emergency room.

I would propose a replacement benefit of $0 for the first visit and $20 for each subsequent one, in a given calendar year. Not every state, but any state that reaches certain thresholds for physician access or urgent care availability may switch to this policy.

Here are the arguments in favor. First, each $3 visit costs the state and federal government about $500. There are few discretionary or semi-discretionary patient decisions that cost so little to trigger so much taxpayer spending. (Hospitalizations have that kind of ratio, but a patient can’t check himself into a hospital the way he can visit an ER.)

Second, one must consider the historical context. The $3 copay (“$3” is a shorthand for $0 to $10 — I don’t think it is over $10 anywhere) is a vestige of the bad old days when it was very difficult to find physicians who accepted Medicaid patients. That is still the case in some locales; they would not be eligible for this waiver. The world has changed, but the copay hasn’t.

Third, ER utilization rates in the TANF population, which because of its average age is generally pretty healthy, far exceed that of the commercially insured population. This is despite the fact that TANF members in general cost much less than commercially insured people, a gap that widens still further once birth events are removed from the calculation. Clearly there is much excess utilization.

Study Says, Something Other Than What We Were Expecting. EHR Portals Increase Hospitalization Rates

Nov 21, 2012• 40

By Jaan Sidorov, MD

Hey there Accountable Care Organization executive.

You’re probably willing to continue to commit millions of dollars toward an electronic health record (EHR) coupled to an online patient portal. That’s because you’ve been told by your leadership team that electronic consumer empowerment, patient-provider communication and the substitution of efficient two-way messaging for costly face-to-face visits will increase quality, reduce expenses, generate shared savings and guarantee that your life-sized portrait will be prominently displayed in your flagship hospital’s lobby.

Well, after you’ve read a just-published JAMA research study by Ted Palen, Colleen Ross, David Powers and Stanley Xu, you may want to tell your administrative assistant to cancel that appointment with the portrait artist.

The article’s title is Association of Online Patient Access to Clinicians and Medical Records With Use of Clinical Services.

How the study was done:

Kaiser Permanente Colorado added “MyHealthManager” (MHM) to their EHR in May 2006. MHM allows patients to view tests, records, problem lists as well as care plans, schedule appointments, request refills and message their doctors. By June of 2009, over 375,000 Kaiser patients had signed up for MHM. Of those, about 45% had used the system at least once. Of this number, Kaiser researchers pulled the records of 44,321 persons who had been continuously enrolled in the Kaiser system for at least two years.

Cigarettes Should Cost $25 a Pack

Nov 21, 2012• 45

By Vijay Govindarajan and Srikanth Srinivas

Henry David Thoreau said, “There are a thousand hacking at the branches of evil to one who is striking at the root.”

We have hacked at healthcare costs for what seems like thousands of times, with very limited success. It is time to strike at the root. Rather than focus on reducing costs after preventable diseases have taken hold, it is time to focus attention on eliminating the disease.

Let us look at two specific examples.

1. The CDC (Center for Disease Control and Prevention) has estimated that the cost of smoking(estimated cost of smoking-related medical expenses and loss of productivity) exceeds $167 billion annually. The CDC has also estimated that 326 billion cigarettes (combustible tobacco, to be more precise) went up in smoke in 2011. In other words, every cigarette consumed costs the nation about 50 cents; every pack, $10.

Put another way, while the smoker paid approximately $5 a pack up front, there was also an additional $10 secret surcharge — the cost of which is born by all of us (such as taxpayers, anyone who buys health insurance, even private companies who suffer from lower productivity as a result). It is as if we are telling the smoker, “I know you can’t afford to pay $15 for a pack. So we will give you $10 so you can afford to smoke.” We are not this generous even with people who don’t have one square meal a day. We spent $78 billion on food stamps, with constant pressure to bring that down further even if some people will be left without food as a result.

‘Reducing Cancer Among Women of Color’ App Challenge

Nov 21, 2012

By J. Nadine Gracia, MD

Photograph Dr. J. Nadine Gracia is the Deputy Assistant Secretary for Minority Health (Acting) Calling all software developers, entrepreneurs, and innovators – the Department of Health and Human Services (HHS) seeks your help in empowering women in minority and underserved communities to fight and prevent cancer.

Each year, more than 300,000 new cases of breast, cervical, uterine, and ovarian cancer are diagnosed in the United States. While these diseases touch every community, disparities in education, prevention, early treatment, quality of care, and access to support mean that minority and underserved women bear a disproportionate burden.

In the face of these disparities, HHS has launched a new challenge to help turn the tide: the “Reducing Cancer among Women of Color” App Challenge. The challenge invites developers to create an application (app) for mobile devices that can help improve the prevention and treatment of breast, cervical, uterine, and ovarian cancer. Up to $100,000 will be awarded for apps that provide high-quality health information to women and community health workers, interface securely with patient health records, and strengthen communication across provider care teams.

This month, as we reaffirm our commitment to promoting prevention and fighting cancer in recognition of National Breast Cancer Awareness Month, we are turning to new platforms and new approaches in our effort to address cancer disparities. We are reaching consumers where they are – recognizing that minorities rely heavily on mobile devices for accessing information. We are turning to new technology, and sourcing solutions directly from those who understand it best. And we are raising awareness about health equity among new audiences – including those who are already dedicated to thinking innovatively about solutions for tough challenges.

Skilled Nursing Providers Playing an Increasing Role in Reducing Hospital Re-admissions

Nov 21, 2012• 6

By Jonathan Hill

The $200 billion skilled nursing and rehabilitation market is in the midst of a transformation and in a new world of ACOs and readmission penalties, we see these providers playing a significant role in helping hospitals reduce readmissions and providing patients with coordinated and professional care in a sub-acute environment.

In March 2012, the Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation announced the Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents. Through this initiative, CMS is partnering with seven organizations to implement strategies to reduce avoidable hospitalization for dual eligibles who are typically long-stay residents at nursing facilities. Each participant in the initiative is required to partner with a minimum of 15 dual eligible certified nursing facilities in the same state where the intervention will be implemented.

Denying Reality About Bad Prognoses

Nov 19, 2012• 10

By Bob Wachter, MD

The human capacity to deny reality is one of our defining characteristics. Evolutionarily, it has often served us well, inspiring us to press onward against long odds. Without denial, the American settlers might have aborted their westward trek somewhere around Pittsburgh; Steve Jobs might thrown up his hands after the demise of the Lisa; and Martin Luther King’s famous speech might have been entitled, “I Have a Strategic Plan and a Draft Budget.”

Yet when danger or failure is just around the corner, denial can be dysfunctional (see Karl Rove on Fox News), even suicidal (see climate change and Superstorm Sandy).

Healthcare is no exception. Emerging evidence suggests that patients and their surrogates frequently engage in massive denial when it comes to prognosis near the end of life. While understandable – denial is often the way that people remove the “less” from “hopeless” – it can lead to terrible decisions, with bad consequences for both the individual patient and society.

First, there is evidence that individuals charged with making decisions for their loved ones (“surrogate decision-makers”) simply don’t believe that physicians can prognosticate accurately. In a 2009 study, UCSF’s Lucas Zier found that nearly two-thirds of surrogates gave little credence to their physicians’ predictions of futility. Driven by this skepticism, one-in-three would elect continued life-sustaining treatments even after the doctor offered their loved one a less than 1% chance of survival.

In a more recent study by Zier and colleagues, 80 surrogates of critically ill patients were given hypothetical prognostic statements regarding their loved ones. The statements ranged from “he will definitely survive” to “he will definitely not survive,” with 14 statements in between (including some that offered percentages, such as “he has a [10%, or a 50%, or a 90%] chance of survival”). After hearing these statements, surrogates were asked to interpret them and offer their own survival estimates.

When the prognosis was optimistic (“definitely survive” or “90%” survival odds), surrogates’ estimates were in sync with those of the physicians. But when the prognosis was pessimistic (“definitely not survive” or “he has a 5% chance of surviving”), surrogates’ interpretations took a sharp turn toward optimism. For example, surrogates believed that when the doctor offered a 5% survival chance, the patient’s true chance of living was at least three times that; some thought it was as high as 40%. Remarkably, when asked later to explain this discordance, many surrogates struggled. Said one, “I’m not coming up with good words to explain this [trend] because I was not aware I was doing this.” The authors identified two main themes to explain their findings: surrogates’ need to be optimistic in the face of serious illness (either as a coping mechanism for themselves or to buck up their loved one), and surrogates’ beliefs that their loved one possessed attributes unknown to the physician, attributes that would result in better-than-predicted survival (the “he’s a fighter” argument).