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What We’ve Learned from Horizontal and Vertical Integration of Physicians

flying cadeuciiAs health care reform rolls out, there is a growing focus on restructuring the health service delivery system in the hope of improving health care quality and “bending the cost curve.”

A key part of this focus has been on physician organization and, in particular, moving toward large, multispecialty physician groups or hospital-physician systems that can provide integrated, coordinated patient care (e.g., through “Accountable Care Organizations”).

In a recent chapter in Advances in Health Care Management’s Annual Review of Health Care Management, however, we and our co-author Jeff Goldsmith find that there is little evidence for the superiority of these integrated models in terms of patient care quality or cost-savings, and that the trends toward physician consolidation has been much less dramatic than is often thought.

Using data from a variety of sources, we find there are two separate phenomena at work in physician organization. At one end of the spectrum (bottom tail of the size distribution of physician groups), the majority of physicians continue to practice in small groups, although there has been some movement from really small practices (one to three or four physicians) to slightly larger groups (five to nine physicians).

Still, nearly two-thirds of office-based physicians continue to practice in solo settings, two-person partnerships, and small (usually single specialty) groups with five or fewer physicians.

At the other end of the spectrum (upper tail of the distribution), however, is a smaller number of very large and rapidly growing multispecialty physician groups, which are often owned by hospitals, health plans, private equity firms, or other non-physician sponsors.

These two stories of what is happening in the distribution of physician group size are described as “a tale of two tails.”

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The Medical Chart: Ground Zero for the Deterioration of Patient Care

emr note

EMR Alert – Featuring radiologist note in illegible font color

For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.

I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.

I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.

This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.

While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.

What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?

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Why Are Al Lewis and Vik Khanna Such Jerks?

flying cadeuciiRecently, The Health Care Blog published a post by Robert Sutton asking why there were so many jerks in medicine.

That posting made the underlying assumption that being a jerk is a bad thing.  In response, we are posting today a defense — really more an explanation of the features and benefits — of jerkdom, at least in our segment of healthcare, wellness and outcomes measurement.

In 1976 an obscure graduate student named Laura Ulrich (now a Pulitzer Prize-winning professor) wrote: “History is seldom made by well-behaved women.”   That statement could be applied much more broadly.  In any field governed by voluntary consensus – especially where the consensus specifically and financially benefits the people making the consensus – radical change does not happen jerklessly.

The best current example might be the critique of Choosing Wisely in the New England Journal of Medicine in which it was pointed out that only three specialty societies blacklisted controversial procedures still performed in significant enough quantity to affect that specialty’s economics.

(Another example of financially fueled consensus gone awry is the RUC, also frequently and justifiably excoriated in The Health Care Blog and elsewhere.)

Specifically, there are three reasons we act like jerks.   (Four reasons if you include selling our book, but we acted like jerks well before our book came out.)

First, as Upton Sinclair said, “You can’t prove something to someone whose salary depends on believing the opposite.” Hence, making nice rarely works and may backfire when you are pointing out a total waste that  also happens to be someone else’s income.

After Community Care of North Carolina (CCNC) sponsored an outcomes study  by Mercer finding massive savings through their patient-centered medical home (PCMH) in an age cohort (children under one year of age) in which no utilization reduction took place and which, as luck would have it, was not enrolled in the PCMH anyway, we kindly wrote to them and offered to show them the error of their ways, privately.

We didn’t get a response.  We repeated the offer when they put out another RFP for even more validation, pointing out that using the HCUP database meant no RFP was needed — we would be able to give them an answer in less time than it would take them to evaluate the RFP responses, and save them close to $500,000 in taxpayer money too.

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Placing Diagnosis Errors on the Policy Agenda

Robert Berenson“Not everything that counts can be counted, and not everything that can be counted counts.”

This aphorism has been deliciously, but, alas, incorrectly attributed to Albert Einstein (the saying actually has mixed origins, but credit properly might be given to sociologist William Bruce Cameron, writing in 1963).

But, whatever its provenance, the saying is particularly appropriate in describing the woeful lack of attention paid to the long-standing problem of diagnosis errors in the provision of health care services.

Last week academic researchers from Baylor and the University of Texas published important research estimating that one in 20 adults in the U.S., or roughly 12 million people every year, receive an error of diagnosis—a wrong, missed or delayed diagnosis—in ambulatory care.

This likely represents a conservative estimate of the incidence of such errors in ambulatory care and does not attempt to include inpatient hospital care or care provided in nursing homes and post-acute care facilities, such as rehab hospitals.

The news media correctly decided that this peer-reviewed finding deserved prominent attention—it was a lead story on “NBC Nightly News” and other national news programs.

It seems that attaching a large number to the prevalence of such errors provided the needed news hook to give the problem the attention it has long deserved. Surveys reveal that the public is worried as much about a misdiagnosis or missed diagnosis as any other quality and safety issue in health care.

Autopsy studies performed over time find that unacceptably high rates of diagnosis errors persist; similarly, diagnosis errors continue to represent a leading cause of medical malpractice suits.

But even without newsworthy body counts, the problem of diagnosis errors has been known to clinicians for decades, if largely ignored by stakeholders and policy-makers as a major quality and safety problem.

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The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.

flying cadeuciiDid you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.

Good thing he didn’t say an act of God.

So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?

The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.

First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.

An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.

“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”

“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”

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Moore’s Law in Healthcare – Three Predictions

apple storeJe n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. —Blaise Pascal

Translation: I have made this longer than usual because I have not had time to make it shorter.

As Appley as it gets.

A while ago I was challenged to write about what an Apple-like approach to healthcare might look like.

That challenge has been weighing on me.

For starters, we’re all over Appled aren’t we? Maligned anecdotes about Steve Jobs and the iPhone make their way into almost every presentation remotely related to innovation or technology. Triteness aside, I’ve been stalled because Apple is really a philosophy, not a series of steps or lessons learned. (Although, they are nonetheless methodical.)

Instead, what I’ve been kicking around in the ole noggin are three notional predictions, which I’ll assert are inevitabilities which will fundamentally disrupt healthcare delivery as we know it today.

What follows is about as Appley as I’m likely to get. Despite big-bang product launches, Apple actually plays the long game. They introduce small features into products to affect user behavior years before a flagship product takes advantage of those reprogramed behaviors.

That’s how they disrupt.

I believe there are three meaningful, unstoppable trends, in our current world which will significantly alter healthcare. The steps taken towards these inevitabilities, along the way, are what will define the innovators and leaders. They are the ones who see this future and know how to drive towards it.

The three trends are:

  • Tools and culture which favor individual empowerment
  • The commoditization and automation of diagnosis
  • Accelerated globalization of treatment options

But wait, there’s Moore.

Don’t worry, I’m not going to leave you hanging. I’ll attempt to rationalize each of these points and explain why, particularly when considered as a bundle, they are a powerful force for disruption. And to prime that pump, we have to talk about Gordon Moore.

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Obamacare Observations from the Marketplace

flying cadeuciiA few observations from my travels and conversations in the marketplace:

About half of the enrollments are coming from people who were previously insured and half are not. When I try to gauge this, I go to carriers who had high market share before Obamacare and have maintained that through the first open enrollment. Some carriers have said only a small percentage of their enrollments had coverage before but health plans only would know who they insured before.

By sticking to the high market share carriers who have maintained a stable market share and knowing how many of their customers are repeat buyers, it’s possible to get a better sense for the overall market. Other conventional polls have suggested the repeat buyers are closer to two-thirds of the exchange enrollees.

The number of those in the key 18-34 demographic group improved only slightly during the last month of open enrollment so the average age is still high. The actuaries I talk to think this issue of average age is made to be far more important than it should be. It is better to have a young group than an old group. But remember, the youngest people pay one-third of the premium that older people pay.

The real issue is are we getting a large enough group to get the proper cross section of healthy and sick?

The bigger concern continues to be the relatively small number of previously uninsured people who have signed up compared to the size of the eligible group. The recent report released by Express Scripts reporting on very costly pharmacy claim experience from January and February enrollees is far more concerning than the average age.

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Make Sense? Competition, Not Higher Premiums, May Turn Out to Be the Biggest Threat to Obamacare Buyers

flying cadeuciiThere have been lots of news reports, including some from me, about insurers raising premiums 10 percent or more on the Obamacare exchanges next year.

But for most people who bought health coverage in the Obamacare exchanges, that’s not really a concern.

That’s because the vast majority of Obamacare buyers so far have received tax credits to reduce the cost of that coverage.

Those subsidies, rather than being flat dollar amounts, fluctuate so customers never pay more than a certain percentage of their incomes on insurance.

In other words, if premiums rise next year like WellPoint Inc. has predicted, subsidies also will rise to keep the net cost to consumers at the same percentage of their income.

So rising premiums aren’t a problem for consumers, unless their income rises so much that it reduces the size of their subsidy.

“If all insurers increase their rates by 10 percent, that might not have a dramatic shift in the market,” said Paul Houchens, a consulting actuary at the Indianapolis health practice of Milliman Inc. “Most of that premium increase is going to be absorbed by the federal government.”

(Rising federal spending could also be a problem for Obamacare–not to mention taxpayers–but that’s not my focus today. Also, Houchens noted, Obamacare’s premiums are not scheduled to rise in line with premiums forever, but will be indexed to income growth and inflation.)

But for 2015, what could cause the biggest problem for Obamacare consumers, Houchens pointed out to me last week, is if an insurer reduces its premiums. Or if a new compeitor enters the market in 2015 with lower premiums than insurers were offering in 2014.

If that idea makes your head spin, welcome to Obamacare, where up is down and down is up—at least compared to how health insurance used to work. It’s what I’ve taken to calling the weightlessness of Obamacare.

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Would You Get a Brain Implant if It Could Make You Smarter?

Screen Shot 2014-04-22 at 12.34.50 PM

Yesterday the Pew Research Center’s Internet & American Life Project released the findings of their survey on the future of science. 1,001 participants were read a list of scientific innovations that may or may not happen in the next 50 years.

The respondents reported how likely these innovations were to occur, whether they believed such a change was a positive development, and whether they would personally use these new technologies.

Here are some highlights from the survey:

Custom Ordering Organs
Americans are confident that people in need of an organ transplant will have new ones custom made for them in a lab. 22 percent of Americans say that scientists will definitely be able to custom make organs for those in need, 60 percent think it will probably happen.  Only 15 percent of Americans think it will probably or definitely not happen.

Controlling DNA
Americans are not fans of genetic engineering.  66 percent of respondents say that we will be worse off if prospective parents can alter the DNA of their children to produce smarter, healthier, or more athletic offspring. About one-in-four Americans think scientists striving to create perfection by developing the ability to control the DNA of offspring would be a positive change.

Growing Meat
A large percentage of those surveyed are turned off by the thought of test tube meat.  78 percent of Americans would not eat meat that was grown in a lab.  22 percent of Americans reported they were comfortable eating lab grown meat.

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Diagnosis Is Not Therapy

PAMWe all know “that patient” – the one we may dismissively label “noncompliant.”

The person with diabetes whose HA1C is consistently above normal limits – the one who swears, when confronted with the numbers (yet again) he’ll start eating right and using his insulin as prescribed.

And yet, month after month, the lab work tells a different story. We watch in helpless frustration as patients like these spiral downward, developing complication after complication.

I thought about “that patient” as I read a recent Wall Street Journal article describing Dr. Judith Hibbard’s Patient Activation Measure (PAM), which she and her colleagues at the University of Oregon developed some years ago.

First, let me say I greatly admire the research and work of Dr. Hibbard and her team; I believe that the PAM is a wonderful tool and a step forward in better understanding patients.

While the article, and Dr. Hibbard, argue that the use of the tool can better target the needs of patients – and I agree – I can’t help but worry that the entire premise that patients need to be “activated” misses a point.

Patients are people before they are patients.

We know that when people are sick, they are still part of their broader world of family, friends and finances. We also know that their social, spiritual and psychological selves are every bit as important, and as important to their “cure” as their activation as a patient.

I suspect that Dr. Hibbard would agree with me and even argue that the PAM reflects all of these factors.

PAM is accurately diagnosing the end state – how all these factors impact the patient and the patient’s ability to be involved in his or her own care.

I worry, however, that the PAM may be oversold by healthcare administrators who put it in place as a way of trying to address all the factors that affect patient activation.

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