A recent tweet from JAMA, the journal of the American Medical Association, urged me andother doctors to “include nutrition counseling into the flow of [our] daily practice.”
My response to the tweet was swift and knee-jerk. I will not do it. I simply will not. I refuse to follow dietary guidelines or recommend them to my patients.
“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!” I imagine my outraged critics erupting in a chorus of disapproval.
Is my reaction unwarranted? After all, the recommendations themselves seem sensible enough: Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables. What’s not to like?
I don’t know. Perhaps it’s dietary guideline fatigue.
For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid. But what have they got to show for? The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!
The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.
Take the recommendations in the JAMA article. Even though the authors claim that only “small steps” need be taken, the whole message occupies 2 pages of fine print. What’s more, the doctor is supposed to start the process by asking patients to fill out a questionnaire. Who has the appetite for yet another questionnaire?!
The recommendations themselves come in the usual manner of adding or subtracting “servings:” increase vegetables by one serving per day; decrease sodas by one serving per day; replace one serving of crackers with one handful of nuts, etc…
But why think about meals in terms of discrete servings of food and beverage stuff? A meal is one thing, one experience. To break it up into physico-chemical or caloric components makes sense for laboratory animals, and perhaps for patients with serious metabolic disorders. But does it really work for most human beings in their natural environment?
The idea that payment should be linked to the value lies at the heart of most of the transactions we participate in on a daily basis. Yet, value based payment in healthcare has seemingly run into very rocky waters as of late. It is at this precarious time that stakeholders representing large employers and other purchasers of health care’ took to the Harvard Business Review to write in defense of value based payment reform. The authors pepper their article with cherry picked ‘successes’ of the value movement and urge the country to forge ahead on the current path. The picture that comes to my mind hearing this is of the Titanic, forging ahead in dark waters, never mind the warning signs that abound.
One of the authors of the paper – Leah Binder – is President and CEO of the Leapfrog Group – a nonprofit organization founded in 2000 dedicated to triggering ” giant leaps forward in the safety, quality and affordability of U.S. health care by using transparency to support informed health care decisions and promote high-value care”. This is a laudable goal, but it is very much predicated on the ability to measure value. A perusal of the Leapfrog group’s homepage notes a 1000 people will die today of a preventable hospital error.
The warning is explicit – choosing the hospital you go to could be the difference between life or death. I have spent some time in the past about the remarkably weak data that lead to an estimate of 400,000 patients dying per year in hospitals due to medical errors, but suffice it to say the leapfrog group subscribes to the theory that of the ~700,000 deaths that happen in hospitals per year, half are iatrogenic. With no exaggeration, I can say firmly that those who believe this are in the same company as those who believe the earth is flat. If the home page of the Leapfrog group, examination of their claims in their HBR article merits additional concern.
The Four Things Keeping Hospital CEOs Awake at Night This Year (Hint: Donald Trump Isn’t One of Them)
The Center for Medicare and Medicaid Innovation released a Request for Information (RFI) last week– “New Direction for the CMS Innovation Center.” It’s the latest chapter in the unfolding policy framework that will govern the health system for at least the next 3 years.
The RFI, which doubles down on value-based alternative payment models and consumer directed care, coupled with a proposed rule to cancel mandatory bundles by former HHS Secretary Price, the administration’s actions last week to weaken contraceptive coverage requirements in employer-sponsored health plans and Congress’ FY18 federal budget that include cuts in Medicare and Medicaid funding provide a sobering context for hospital and health system strategic planning. But hospital CEOs have adapted to the new normal from DC: uncertainty about the laws governing our health system is standard fare.
Last month, I interviewed 13 hospital CEO’s in preparation for their upcoming Board-Management strategic planning retreats. They lead organizations in 11 states with substantial differences in the scale, scope and strength of their operations and the dynamics in their markets. Two are academic medical centers, six are independent multi-hospital systems and five operate in multiple markets. When I asked “what’s keeping you awake at night” their answers were the same.
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.
As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare quality and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark. At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job. Unfortunately, the parental vaccine hesitancy trend is gaining in popularity. Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically.
Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter. Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws. Immunization rates are used to rate the primary care physician despite the fact we have little influence on the outcome according to scientific studies. Physicians practicing in states with a broad vaccine exemption laws is left with two choices: refuse to see children who are not immunized in accordance with the CDC recommendations or accept low quality ratings when caring for children whose parents with beliefs that may differ from our own.
Massachusetts passed a massive medical cost control bill in 2012, a “Hail Mary” effort to make health-care more affordable in the nation’s most expensive medical market. The problems of the Massachusetts’ law offer invaluable lessons for the nation’s health-care struggles.
Driven in part by a Boston Globe investigation that exposed the likely collusion of the Partners Healthcare hospital system (including several Harvard Medical School teaching hospitals) with Blue Cross/Blue Shield, the largest healthcare insurer in the state, the law marked the biggest health reform since Romneycare in 2006. While most agree Massachusetts needed cost controls, there’s no evidence that the 2012 law has accomplished its goal—and these same failed policies have been folded into the national Affordable Care Act.
Romneycare, Massachusetts’ universal health-care law, already lacked effective rules to control the rapid growth of state medical costs. That, paired with the Boston Globe’s exposure of the likely collusion between Partners Healthcare, the largest hospital system in New England, and Blue Cross Blue Shield to raise health care payments to hospitals and doctors by as much as 75 percent, led to passage of a hefty, 349-page cost-control law in 2012. The legislation included a dizzying number of committees, an uncoordinated “cost containment” process, and dubious quality-of-care policies, like “pay-for-performance,” a program that pays doctors bonuses for meeting certain quality standards, like measuring blood pressure. These incentives might make sense in economic theory, but have failed repeatedly in well controlled studies. They’ve even created perverse enticements, such as some doctors avoiding sicker patients. The cost control law also encouraged widespread use of expensive electronic health records, even though there’s no evidence that they save any money.
Dr. Simon Kos had big shoes to fill when he took over the role of Microsoft Chief Medical Officer from Dr. Bill Crounse last year. Dr. Kos said himself that they were some “big scrubs to fill”. However, at the time he had already been with Microsoft for six years and in Health IT for more than a decade before that, so he was no doubt up to the challenge.
As Chief Medical Officer, Dr. Kos is responsible for providing clinical guidance, worldwide thought leadership, vision and strategy for Microsoft technologies and solutions in the healthcare industries. He made the move to Health IT after working a few years as a Medical Officer in Sydney, Australia. It was then that Kos decided to go back to school to study software engineering, and later his MBA. He then worked with InterSystems and Cerner and helped them to implement e-Health initiatives in Australia. In 2010 he joined Microsoft as a Health Industry Manager “with the appreciation that improving health and healthcare was about more than just putting in EMRs.” Even back then Dr. Kos had the vision to know that the future of healthcare would be in the data analytics and the AI applications that Microsoft would eventually release.
In a recent conversation, with the team here at Health 2.0, Dr. Kos talked about Microsoft’s current framework of digital transformation and highlighted their four pillars; Patient Engagement, Clinician Empowerment, Advanced Analytics, and New Models of Care. As a once practicing doc, he knows that technology needs to help not hinder the healthcare workforce and that AI will be able to improve diagnosis speed and accuracy without replacing or interfering with the clinician. He is a fervent believer that it is important to be constantly evaluating the tech models that may not be viable today but will be in the future. He is excited about Microsoft’s work on patient chatbots and VR/Mixed reality physician education platforms and will be demoing that technology on the Health 2.0 Stage on Monday, October 2nd.
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 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.
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.