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Category: OP-ED

Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect

There’s a debate in the United States about whether the current measures of health care quality are adequate to support the movement away from fee-for-service toward value-based payment. Some providers advocate slowing or even halting payment reform efforts because they don’t believe that quality can be adequately measured to determine fair payment. Employers and other purchasers, however, strongly support the currently available quality measures used in payment reform efforts to reward higher-performing providers. So far, the Trump administration has not weighed in.

The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts for the following three reasons:

Even imperfect measurement and transparency accelerate quality improvement. One set of measures often questioned is the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) used by the Centers for Medicare and Medicaid Services (CMS) and others in value-based payment programs. These indicators measure surgical complications and errors in hospitals, which is critical given that one in four hospital admissions is estimated to result in an adverse event.

PSIs remain among the most evidence-based, well-tested, and validated quality measures available. CMS uses many in its value-based purchasing programs. Use and reporting of PSIs through AHRQ’s Medicare Patient Safety Monitoring System has measurably improved quality. For instance, CMS reported a reduction in inpatient venous thromboembolisms (VTEs) from 28,000 in 2010 to 16,000 in 2014, meaning that 12,000 fewer patients had potentially fatal blood clots in 2014.

In addition to using quality measures in payment programs and for quality improvement, making measures public is key to accelerating change. “If transparency were a medication, it would be a blockbuster,” concluded a multi-stakeholder roundtable convened by the National Patient Safety Foundation’s Lucian Leape Institute in 2015. The foundation’s report cited the Leapfrog Group’s first-ever reporting of early elective delivery rates by hospitals in 2010, which galvanized a cascade of efforts to curtail the problem and thus reduce maternal harms and neonatal intensive care unit (NICU) admissions. This was effective: The national mean of early elective deliveries declined from a rate of 17% to 2.8% in only five years.

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I’m 35 Years Old And I’m Realizing My Life May Be About to End. And I’m Panicking, Just a Little.

It’s been a while since I put a piece of writing in the public domain, but suddenly I have a lot to get off my chest, well my colon actually.

Just three weeks ago life was good. Correction. It was awesome. The newest edition to our family had arrived on Christmas Eve, joining his two sisters aged 5 and 3. A month later we were on a plane home to Sydney, having spent four great years working for Google in California. My beautiful wife had been working at a startup on NASA’s Moffett campus and was worried about finding something equally interesting in Australia, but she managed to land a very similar gig with an innovative logistics start-up in Sydney. We’d come back primarily to be closer to family, but also to pursue a dream of setting up a family farm in partnership with my parents — intended as a great place to bring up our three kids but also as a new sideline income stream. We’d spent every weekend scouring Sydney for areas that met our criteria (good schools, commutable, cost of land etc) and we were settling on Kurrajong in Sydney’s west. I was just getting into a training routine for the CitytoSurf run having done the Monteray Bay half marathon a few months prior.

I’m 35 years old.

On July 19th I went for what I thought would be a routine GP visit. In my mind it was primarily to re-establish a GP relationship in case my kids needed an urgent care visit (the practice is literally around the corner from our place). I’d also noticed a bit of unusual bleeding from, well, my back passage and very recently a change in bowel habit. I wasn’t alarmed by either of these symptoms but my GP was concerned enough to refer me for a colonoscopy. So began the roller coaster.

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Why Competition In the Politics Industry Is Failing America

Year after year, Congress fails to reach consensus on important issues, the electorate screams for change, and voters become more polarized along party lines and ideology. These struggles aren’t causes of America’s political malaise, says Michael E. Porter, co-chair of the U.S. Competitiveness Project at Harvard Business School; they’re symptoms of a much larger problem. U.S. “democracy” is a weak, uncompetitive industry controlled by a duopoly that pursues private interests at the expense of public good.

“To fix our political system, we must see politics as the major industry it has become, the major economic benefits it provides for its participants, and how today’s political competition is not serving the public interest,” as Porter explains in “Why Competition in the Politics Industry Is Failing America,” a just-released groundbreaking study co-authored with business leader and former CEO Katherine M. Gehl.

Experts in the benefits and drawbacks of competition in the private sector, Porter and Gehl describe the four fundamentals of a healthy political system:

  1. Practical and effective solutions to solve our nation’s important problems and expand opportunity
  2. Legislative action to advance those solutions
  3. A reasonably broad-based public consensus on policy
  4. Respect for the Constitution and the rights of all citizens

Measured by these success factors alone, America’s system has already failed. But Porter and Gehl are adamant in their belief that we can recover our former sense of bipartisanship and dynamism.

Read Porter’s and Gehl’s paper to learn more about their poignant perspective on our nation’s most urgent problems and how business, strategy and competition can help solve them.

Danny Stern is Managing Director of the Stern Strategy Group

Hi, I’m Rob. I’m a Recovering Doctor

Yeah, I know I used that line once before, but it’s a special day for me today.  Humor me.  Five years ago today I earned my last money from an insurance company.  Yep, today is my five year sobriety date.

Five years.

That was before the Affordable Care Act, before the Cubs won the World Series.  Before anyone knelt for the national anthem, and if they had, people would’ve probably not minded.  It was before the election of a reality TV star to our highest office, before “fake news” became a thing (there was plenty of it, but nobody called it that).  It was before half of the rock legends died, before Anthony Wiener went to jail, back when Hamilton was a guy nobody knew much about who was on the 10 dollar bill, when the world wasn’t quite this warm, when Oprah hated me.  Actually she still does.  I’m not sure why.

I left my old practice because of “irreconcilable differences” with my ex-partners.  Instead of going to the VA, joining another practice, or moving to New Zealand, I started a different kind of practice.  My Yoda, Dave Chase (who wrote a book that you MUST read) told me about “Direct Primary Care,” where doctors don’t charge a lot, but are able to see a lot of people and give good care because they are paid by their patients.  It made sense to me.  There were a few folks doing it, and I talked to a couple (I’m looking at you, Ryan) who made it sound possible.

So I did it.  I dumped all insurance and started charging people a flat monthly fee.  People were skeptical and only my most loyal patients followed me (about 200).  It took a while, but we figured out how to make it work, and my patients figured out that this was the best experience they ever had in healthcare.

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An Op-Ed Ghostwriter Speaks

Is it “a breach of trust” for a publication to publish an opinion piece that was written with the participation of public relations professionals?  That was the conclusion of a recent article in Health News Review, a publication that bills itself as “Your Health News Watchdog.”(“Another ‘breach of trust’ at STAT: patient who praised TV drug ads says pharma PR company asked her to write op-ed”).

The article traces the origins of an op-ed that appeared in STAT, the respected medical blog published by the Boston Globe,  headlined  “You can complain about TV drug ads. They may have saved my life.” Health News Review managing editor Kevin Lomangino found that a public relations firm working for Gilead, a pharmaceutical company that makes the hepatitis C drug Harvoni, had reached out to a patient named Deborah Clark Duschane and asked her to write about her experience with drug ads.

Lomangino quotes Charles Seife, a professor of journalism at New York University, who called the situation a “breach of trust.”

“The whole point of ghostwriting is to hide the hand of an actor — to make an industry position seem like it’s coming from an unaffiliated individual,” Seife said. “That’s deception. It’s meant to disarm the natural skepticism that we have when an industry makes self-serving statements. And when someone tries to disarm our skepticism, well, it ain’t good.”

As a professional ghostwriter, who has been hired by public relations professionals to work with authors on op-eds that have run in respected publications, I disagree.

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Maintenance of Certification: Who’s Regulating the Regulators?

When four physician certification boards founded the American Board of Medical Specialties (ABMS) in 1933, those forward thinking organizations—and their professional society sponsors—launched a national movement toward ever increasing physician accountability. Back then, quackery was rampant, so “board certification” meant a lot to patients. The ABMS has since grown to 24 member boards, all ostensibly dedicated to serving “the public and the medical profession by improving the quality of health care through setting professional standards for lifetime certification.”

Because information and technology now advance so rapidly, those one-time lifetime certificates from years ago may no longer be enough. A doctor who passed a test in 1990 isn’t necessarily competent today. The boards have thus changed their approach to certification; for newly minted physicians, time-limited (e.g., 10 year) endorsements now replace the lifetime ones granted to their predecessors. Initially contingent on additional examinations each certification cycle, these newer time-limited endorsements now additionally require ongoing participation in Maintenance of Certification (MOC®) programs.

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How the Government is Failing Health Tech Startups and What to Do About It

As the Senate debated the fate of the Affordable Care Act (ACA) in Washington this past summer, healthcare was front and center in newspapers and conversations around the country. While insurance coverage and the affordability of care certainly warrant the level of nationwide attention they received, they comprise only one dimension of the systemic deficits in US healthcare: access to care. Meanwhile, the pressing need to reform our broken delivery and payment structures and address the more than $1 trillion of waste in our system was being overlooked by lawmakers in DC.

Luckily, on the other side of the country, entrepreneurs and venture capitalists throughout Silicon Valley are paying plenty of attention to opportunities to improve the efficiency of healthcare. In the first quarter of 2017, while policymakers fought about repeal-and-replace, investors poured almost $1.5 billion into digital health startups (mostly in the San Francisco Bay Area). This is on top of over $29 billion invested in healthcare startups between 2010 and 2016. Many of these budding companies are poised to significantly improve the way healthcare is administered and enhance the experience of providers and patients in novel, tech-enabled ways. Unfortunately, in addition to the myriad barriers facing any new startup, healthcare startups also encounter several unique obstacles rooted in policy failures that severely limit their potential to disrupt a system badly in need of disruption.

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The High Cost of Public Reporting

In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.

Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear.  He loved guitar playing,  and camp horror movies.  Those who knew him well said he had a kind heart, a quick wit and loved cats.

I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon.  I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack.  Not able to make sense of the story on the phone, I was in to try to sort it out.  Joe was gruff, short with his answers – but clearly something just wasn’t right.   He was only 54 but had more problems than the average 50 year old.   Progressive calcification of his aortic valve  some years ago  had caused intolerable shortness of breath resulting in  replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis,  and most recently abnormal liver tests had  revealed the presence of the early stages of cirrhosis from hepatitis C.  Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.Continue reading…

The Decline and Fall of the Doctor-Patient Relationship

The physician-patient relationship is a bedrock of the U.S. health system. Strong relationships are associated with higher ratings for physicians and better outcomes for patients but there’s a catch.

In Secretary of Health and Human Services’ Tom Price Senate confirmation and many times since, he has vowed his administration will seek to restore that relationship. But what patients associate with a strong relationship is increasingly at odds with how physicians think. And the gap between the two seems to be widening.

Background:

Per the American Medical Association, the physician-patient relationship is a formal or inferred relationship between a physician and a patient, which is established once the physician assumes or undertakes the medical care or treatment of a patient. It is a responsibility physicians don’t take lightly and most believe they do it well.

The physician-patient relationship has been widely studied. A framework developed by Ezekiel and Linda Manuel has been widely used to categorize the four roles physician play in these relationships: guardian, technical expert, counselor, and friend. In interacting with patients, physicians play all four. Researchers have linked a physician’s personality with their bedside manner. Surveys show most physicians lean toward a more paternalistic approach in dealing with patients and the majority think friendships with patients must be approached with caution. Academics have studied the dynamic between physicians and patients, observing that the physician is the ‘power’ figure in most. Studies have linked a physician known to have a prickly personality with more patient complaints and, in some specialties, a higher susceptibility to lawsuits. And physicians routinely compare notes among themselves about problem patients with whom interactions are routinely difficult.

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Hold the Mayo and Save Our Hospital

There is a grassroots movement, 4300 strong, known as “Save Our Hospital” gaining notoriety in Albert Lea, Minnesota.  This story is symptomatic of the fact that hospital consolidation has slowly become a national pastime.  With declining revenue under the Affordable Care Act, mergers increased by 70%, leaving small communities scrambling for healthcare access.  The latest casualty in the ‘hospital-consolidation-for-sport’ trend is Albert Lea, a small city located in Freeborn County, Minnesota.

Known affectionately as the ‘Land between the Lakes,’ it has a population of 18,000 spread over 14 square miles.  Not surprisingly, Mayo is their largest employer; the 70-bed hospital serves almost 60,000 in a region including patients who live in Iowa.  In Rochester, MN, the Mayo Clinic is regarded by many as one of the premier medical facilities in the country.  Originally of humble origins, founder William Mayo opened a practice during the Civil War and later, passed it down to his sons; today, the Mayo Clinic flagship is located in Rochester, Minnesota and plans to become a renowned premier medical destination for the world. 

Corporations with such lofty ambitions tend to make “small” sacrifices along the way; often, on the back of a beloved rural town.  On June 12, Mayo clinic administrators announced they would transition all inpatient services to Austin, more than 20 miles away.  Mayo cited ongoing staff shortages, reduced inpatient censuses, and ongoing financial difficulties as their reasons for hospital closure.  Rural care was mentioned to be at a crisis point, which is an altogether callous assessment of the troubling situation facing communities across this country. 

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