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SuperDocs and Quality Talks: Notes from the Annual Meeting of the Society of Hospital Medicine

Apr 13, 2014• 4

By Bob Wachter, MD

I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it.
As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.

This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.

Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.

The Closing of Hospitals

While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles.

If that.

The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings?

Will payments for non-hospital care (home care, SNFs) be enough to expand their capacity to care for acutely ill patients?

Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease?

These are just some of the known unknowns.

ACA 101: An Employer’s Search for Objective Advice

Apr 10, 2014• 14

By Michael Turpin

In ancient Athens, the philosopher Diogenes wandered the daylight markets holding a lantern, looking for what he termed, “an honest man.”

It seems since the dawn of the consumer economy that customers and buyers have traded most heavily on a single currency – trust.

Three millennia later, our financial system still hinges on the basic premise that the game is not rigged and any trusted intermediary is defined by a practitioner who puts his client’s interests ahead of his own.

Anyone responsible for procurement of healthcare may feel like a modern-day Diogenes as they wander an increasingly complex market in search of transparent partners and aligned interests. The art of managing medical costs will continue to be a zero-sum game where higher profit margins are achieved at the expense of uninformed purchasers.

It’s often in the shadowed areas of rules-based regulation and in between the fine print of complex financial arrangements that higher profits are made.

Are employers too disengaged and outmatched to manage their healthcare expenditures?

Are the myriad intermediaries that serve as their sentinels, administrators and care managers benefiting or getting hurt by our current system’s lack of transparency and its deficit of information?

Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice

Apr 9, 2014• 25

By Iyue Sung & Josh Gray

Figure 1 acaview

With this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth.

2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces.

Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.

With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.

ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients.

athenahealth is a technology and services provider that delivers physicians the tools and support needed to manage the business and clinical aspects of their medical practices. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.

Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics.

We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.

No Meaningful Change to Date in New Patient Volumes

Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether.

If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.

Will the Uninsured Become Healthier Once They Receive Health Care Coverage?

Apr 9, 2014• 12

By David Orentlicher, MD JD

The Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.

At least that’s the conventional wisdom.

But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.

To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.

How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.

In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.

On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.

However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.

Going after the Wrong Doctors

Apr 8, 2014• 13

By Ford Vox, MD

A recent ProPublica expose co-published with the Boston Globe typifies a growing gotcha genre of health journalism that portrays doctors as the enemy in a struggle for honesty and openness in medicine.

These reports make unfounded leaps in their efforts to subject doctors to levels of skepticism once reserved for politicians and lawyers. They’re going to end up doing patients a disservice.

For this particular hunting expedition ProPublica set its sights on Dr. Yoav Golan, an infectious diseases specialist caring for patients at Tufts Medical Center in Boston who also works with pharmaceutical companies developing antibiotics.

But in its zeal to argue how physicians like Golan are corrupting medicine through their industry partnerships, ProPublica went to press without an iota of evidence Golan is corrupt.

A close look at Golan’s impressive career suggests quite the contrary and raises questions about ProPublica’s claim to objectivity.

Yoav Golan is a remarkably bad choice for anyone who hopes to use him as a poster boy of pharma-physician malfeasance.

As Tufts said in a statement in response to the ProPublica story, Golan enjoys international respect in the infectious diseases community and has assisted the development of “two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile.”

(Disclosure: I held an academic appointment at Tufts for one year when I was practicing in Boston, but in another department and I never met Golan before this story.)

That antibiotic, fidaxomicin, is pricey, and you’d think an industry shill would liberally advise its use. Yet Golan and his team advised a Tufts committee setting internal standards for its use that the hospital should heavily restrict the drug. “We were very active in making sure it’s not used in pathways where it’s not cost effective,” Golan told me.

RAND: Net Gain of 9.3 Million American Adults with Health Insurance

Apr 8, 2014• 14

By Katherine Grace Carman & Christine Eibner

Using a survey fielded by the RAND American Life Panel, we estimate a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.

The survey, drawn from a small but nationally representative sample, indicates that this significant uptick in insurance coverage has come not only from enrollment in the new marketplaces established under the Affordable Care Act (ACA), but also from new enrollment in employer coverage and Medicaid.

Put another way, the survey estimates that the share of uninsured American adults has dropped over the measured period from 20.5 percent to 15.8 percent. Among those gaining coverage, most enrolled through employer-sponsored coverage or Medicaid.

Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. Our marketplace enrollment numbers are lower than those reported by the federal government at least in part because our data do not fully capture the surge in enrollment that occurred in late March 2014.

Using the RAND American Life Panel, a nationally representative panel of individuals who regularly participate in surveys, we have conducted monthly surveys since November 2013 about insurance choices and public opinion. This particular survey work—which is ongoing—is known as the RAND Health Reform Opinion Study(RHROS).

We match these data with data collected in September 2013 about insurance choices. The results presented here are based on 2,425 adults between the ages of 18 and 64 who responded in both March 2014 and September 2013.

People shift from one type of health insurance to another for a number of reasons, such as job changes or marital status changes. Our survey work can’t say for certain which of these shifts are due to the ACA and which are due to other factors, but we can draw some limited conclusions.

Fatal Error

Apr 7, 2014• 7

By Rob Lamberts, MD

The janitor approached my office manager with a very worried expression. “Uh, Brenda…” he said, hesitantly.

“Yes?” she replied, wondering what janitorial emergency was looming in her near future.

“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”

“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.

“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.

Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.

Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.

The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”

The Fatal Error in Health Care

Yeah, this makes me nervous too.

We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.

It’s a problem with something that is starts at the very beginning of health care itself.

The health care system is not about health.

Cracking the Code on Health Information Exchange. Is It Time to Wipe the Slate Clean and Start Anew?

Apr 6, 2014• 3

By Bill Crounse, MD

Three related columns in HealthcareITNews caught my attention recently.

The headlines pretty much say it all:

1. Satisfaction with HIE solutions drops.

2. Vendors missing boat on HIE needs.

3. CommonWell names 3 biggest HIE hurdles.

Over the years, I’ve written more than a few HealthBlog posts on the topic of health information exchange (HIE) and why I feel so strongly that most of the initiatives currently underway are missing their mark.

As I’ve stated before, during my worldwide travels I haven’t yet come across a country that has accomplished a truly national, interoperable, bi-directional, fully functional HIE.

Those few countries that come close are more like a large American city or small state in size, perhaps mirroring some of the moderately successful regional or state-wide exchanges currently operating in America. Over the years I’ve also watched implosions of national HIE attempts in several countries that have failed miserably despite billions of dollars being spent on the efforts.

Reading each of the articles referenced above, I once again reach the conclusion that what I have been evangelizing as a better model for HIEs still rings true.

Are We Prepared For The Next Viral Disease Threat?

Apr 6, 2014

By Weaver, Gallo & Hrynkow

Fred Shaw went to St. Martin and all he got was a painful virus called chikungunya.

On an island stop during his Caribbean cruise vacation, Mr. Shaw was infected with the mosquito-borne virus that causes a severe fever and an arthritis-like condition in people, similar to dengue fever. After infection, the virus still may cause long periods of fatigue and incapacitating joint pain.

Writing on Facebook, Mr. Shaw said, “The fever, leg rash and swelling were bad enough, but then followed by months of headache, joint pain and malaise, I finally have gotten over it (I think).”

Chikungunya virus was first described during an outbreak in Tanzania in 1952 and was subsequently discovered in other parts of Africa and Asia. The name ‘chikungunya’ is derived from a local phrase that means ‘that which bends up’ and describes the stooped appearance of sufferers with joint pain.

In late 2013, chikungunya was found for the first time in modern history on islands in the Caribbean. Based on our research and the evidence we have observed, it is likely that the virus is on its way to the U.S.

Vector-borne viruses—which are transmitted to people by an animal or insect—threaten half the world’s population and are responsible for millions of human infections annually. Various mosquitoes and ticks transmit a subgroup of these viruses that are called arboviruses.

There are over 100 known arboviruses that infect humans and can cause neuroinvasive diseases like encephalitis, febrile illnesses and hemorrhagic fevers. Except for yellow fever, tick-born encephalitis and Japanese encephalitis, there are no commercially available vaccines for most arboviral disease.

As the world becomes flatter and the globe opens to new opportunities for international trade and travel, viruses that used to be confined to “over there” are increasingly coming “over here,” and they are arriving sooner rather than later.

The Problem of Pain: When Best Medical Advice Doesn’t Equal Patient Satisfaction

Apr 4, 2014• 23

By Karen S. Sibert, MD

The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic: ”Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.

As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.

The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.