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The Anesthesiologist’s Story: New Details Emerge In the Joan Rivers Case

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By KAREN SIBERT, MD

Screen Shot 2015-01-04 at 9.08.12 AM

New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

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Commentology: The Real Professor Baicker

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By THCBist 

flying cadeuciiInfluential RAND researcher Soren Mattke had this to say in support of Al Lewis and Vik Khanna’s latest post on the Wellness story “Would the Real Professor Katherine Baicker Please Stand Up?”

“Gentlemen. Great post. Like you, I am disappointed that researchers of the caliber of Kate Baicker and David Cutler do not respond to the mounting debate about their paper. They should defend or disown their work rather than hope that the debate goes away.

In my mind, their paper is a product typical of high-end academic research. Two brilliant professors spot a gap in the evidence on a hot policy topic and decide to go after it. But the actual work gets done by a graduate student in his cubicle without windows or guidance, and then hastily published.

Then the problem arises that the paper becomes hugely influential and people start having a closer look. For our paper on the PepsiCo program, we reviewed in detail the seven publications that Baicker and colleagues called “high quality evidence”. We found that five of those analyzed programs that operated over 20 years ago and most of them had severe methodologic flaws. (John P. Caloyeras, Hangsheng Liu, Ellen Exum, Megan Broderick and Soeren Mattke. Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years. Health Affairs, 33, no.1 (2014):124-131)

Unfortunately, many defenders of the industry continue to take the Baicker paper at face value, while closely scrutinizing or ignoring more nuanced and scientifically sound findings.

So I herewith support your motion!

HIT Newser: Accenture Tapped to Continue Work on HealthCare.gov

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flying cadeuciiBy MICHELLE RONAN NOTEBOOM

Accenture Tapped to Continue Work on HealthCare.gov

Accenture, the consulting firm that was hired a year ago to fix the troubled HealthCare.Gov insurance exchange, is awarded a five-year, $563 million to continue its work on the federal site. The government hired Accenture Federal Services to repair the online marketplace after dropping its original contractor, CGI Federal.

The long-term contract with Accenture also signals CMS’s acknowledgement that a task as large as HealthCare.Gov is best run with leadership from an experienced, private-sector vendor.

Connecticut HIE Dissolves After Wasting Millions

A former board member for The Health Information Technology Exchange of Connecticut blames management for the failure of the entity, which was tasked to create statewide HIE but dissolved by the legislature last summer. The HITE-CT “wasted” $4.3 million in federal grants over four years “without accomplishing anything,” according to Ellen Andrews, who served as the board’s consumer advocate.  State auditors also found deficiencies in state controls, legal problems, and a “need for improvement in management practices and procedures.” The state’s legislature is now developing a new exchange strategy.

Prediction: look for more HIEs to falter this year due to mismanagement and lack of sustainability.

Electronic Prescribing of Controlled Substances on the Rise

Electronic prescribing of controlled substances (EPCS) increased from 1,535 to 52,423 between July 2012 and December 2013, according to a study published in the American Journal of Managed Care. The percentage of pharmacies enabled for EPCS jumped from 13% to 30% during the same period.

The next task: figuring out how to get more than the current one percent of physicians to participate.

ONC Shares Lessons Learned from State HIEs

An ONC report on state HIEs finds that many exchanges lack a critical mass of data and are struggling with data sharing. The case study also found that the technical approaches, services enabled, and use of policy and legislation varied across states; collaboration among HIE participants is critical for success; and states are leveraging a variety of policy and regulatory levers to advance interoperability and data exchange.

CMS Seeks ICD-10 Testers

CMS is seeking approximately 850 volunteers for ICD-10 end-to-end testing in April, according to a CMS bulletin. Volunteers have until January 9to submit applications to participate in the April 26-May 1, 2015 testing week.

Pediatrics Report Increased EHR Use

Seventy-nine percent of pediatricians reported using an EHR in 2012, compared to 58% in 2009, according to a study published in the journal Pediatrics.  Only eight percent of physicians say their EHRs include pediatric-specific functionality.

Modernizing Medicine Buys RCM Vendor Aesyntix

EMR developer Modernizing Medicine acquires Aesyntix, a provider of RCM, inventory management, and group purchasing services.

Presumably Modernizing Medicine was most interested in Aesyntix’s RCM component, which may create some concern among Modernizing Medicine’s current RCM partners, which include ADP/AdvancedMD, CareCloud, and Kareo.

Like Air Traffic Control For Healthcare

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By THCBist 

flying cadeuciiIn December THCB asked insiders and pundits across health care to give us their armchair quarterback predictions for 2015.  What tectonic trends do they see looming on the horizon?  What’s overrated?  What nasty little surprises do they see lying in wait? What will we all be talking about this time next year?  Over the next week, we’ll be featuring their responses in a series of quick takes.

Jacob Reider MD, Former Deputy National Coordinator, HHS

As care providers increasingly embrace shared risk payment models, we will see a rapid growth of interest in care coordination and health IT tools that support shared decisions.

a)     Care Coordination.  While this remains a bit of a buzz word, the need for a toolset that helps a community of clinicians care for a group of people in a coordinated manner is obvious to anyone who has been on either end of the stethoscope.  The current health IT tools and processes weren’t developed for this purpose – and therefore do a terrible job of it.  2015 will see the emergence of technology and services that help teams identify and maintain individual patient goals, optimal pathways toward those goals, and then manage the participants toward shared success.  Think of this as “air-traffic control” for health care. If we know where we’re going.  This toolset (and the humans who use it) can help make sure everyone arrives safely.

b)     Do we know where we’re going? Have we made the right diagnosis?  If so – do we have the right treatment plan?  Clinical decisions need to be shared between care providers, patients, family members and other participants.  2015 will see the next step in the evolution of traditional provider-focused clinical decision support (CDS) tools toward tools that also offer research-based personalized care guidance.  This patient’s unique needs can be defined, understood by all parties, and then acted upon.  If care coordination is air-traffic control, perhaps this personalized decision support will be the Waze for health care.  Like Waze, this will take years to reach the mainstream, but when it does, none of us will leave home without it.

2015: The Year Well-Designed Interfaces Will Transform Health IT?

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By THCBist

What else could lie in store? We talked with Nuance’s Nick Van Terheyden, who remains optimistic.

Nick van Terheyden, MD, CMIO, Nuance Communications

flying cadeucii2015 will be the year well-designed interfaces will transform health IT legacy systems into sleeker, more intuitive, and cost-effective technology.

We know that good usability works hand-in-hand with accessibility to remove the burden from the end user, allowing her to focus on more important tasks— and nowhere is this more important than in healthcare.  In the coming year, we will see a major uptick in the availability of secure health IT access on mobile devices that better support physicians in their natural, fast-paced environment, whether it is through clinical speech recognition technology, gestures, or touch.  Physicians are consumers, too, and want and need the convenience of anywhere, anytime access to information.

We will also start to see the breakdown of silos in patient and physician technologies.  The devices we rely on to track our vitals and help us stay active will begin to integrate in meaningful ways with clinical data, providing us with more awareness about our health and supplying our physicians with useful information about our health trends.  Wearables will become a staple, leading to a healthier population and reducing overall healthcare costs.  After all, what good is having a smart watch track all this data if it can’t help keep you healthier?

It’s Official: Aledade ACOs Up and Running

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By FARZAD MOSTASHARI, MD

Farzad MostashariWe launched Aledade on June 18th, and by the end of July we had recruited 80 primary care physicians in 4 states to join us in creating the very first Aledade ACOs. We have been work together ever since- but haven’t been able to talk about our wonderful practices until the official notification from CMS that came today.

We are thrilled to announce that beginning January 1, our two newAledade ACOs will be taking accountability for the care of over 20,000 attributed Medicare patients, and stewardship of nearly a quarter of a billion dollars of health care expenditures each year. We’re building a new delivery system on the foundation of trust between patients and the physicians who have been caring for them in their communities for decades, and enabled and accelerated with cutting-edge technology and analytics.

One ACO will operate in the state of Delaware, in close collaboration with our physician partners and our field team, Quality Insights of Delaware. Our second ACO, the Primary Care ACO, will take the same model spanning three states — New York, Maryland, and Arkansas, where we are also working with local partners like the Arkansas Foundation for Medical Care. Our hand-picked ACOs physician partners are some of the most capable and inspiring primary care physicians in the country. They are leaders in their local, state and national physician associations; they are pioneers of Meaningful Use and Patient Centered Medical Homes; they are much-decorated top doctors in quality; but most of all, they are the pillars of their communities.Continue reading…

Revolutionizing Retail and Health – Walmart drives care into new settings

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BY MATTHEW HOLT

One cannot discuss consumer health without addressing the drastically changing environment of care. At Health 2.0 WinterTech: The New Consumer Health Landscape speakers from Walmart, Target, and Optum will join Matthew Holt to dive into how major retailers are disrupting the way millions of Americans not only access acute care services but also purchase prescriptions, access preventive health services, and more. Ben Wanamaker, Senior Manager of Strategy and Operations at Walmart sat down with Matthew last week to shed light on what 2015 will bring for Walmart’s Care Clinics. 

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Competing With Urgent Care

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By MARC-DAVID MUNK, MD

Screen Shot 2015-01-02 at 8.08.19 AMAbout seven years ago, the California Healthcare Roundtable and HealthAffairs sat down to prepare a white paper on the emerging “phenomenon” of urgent care centers, and what it might mean for primary care. At the time the group couldn’t agree that urgent care was a “disruptive” innovation, but it seemed clear to all participants that it represented a threat to primary care: The rise of UC, the group noted, would lead to 1) less preventive care and 2) concentrate acuity in primary care clinics. They wrote: “[Urgent care] means fewer patients per day, a higher intensity environment for providers, and potentially lower reimbursement.”

In particular, the group couldn’t understand if patients were choosing to leave primary care because they didn’t value having a PCP, or if they were settling for the inherent limitations of UC because cost and convenience outweighed its disadvantages.

 Seventy-five percent  [of UC customers] are women ages 28 to 42 and their children. Some hypothesize that this consumer group thinks of its health care relationships differently than do people of the baby boomer generation and older. The younger cohort often has no “medical home,” while baby boomers and older people tend to view the primary care physician as the center of their medical care. Discussants concurred that what the data do not reveal, however, is whether the medical “homelessness” of this younger group and its high relative use of retail clinics reflect how these consumers want to receive their care or is instead merely their experience (or is a function of the fact that they have fewer chronic conditions and thus need less care and care coordination).

Since the roundtable in 2007, there has been a flood of urgent care centers with ongoing rapid growth. The American Academy of Urgent Care estimates that there are around 9300 UCs nationally. Across the country, clinics are sprouting like flowers, sometimes fueled by private equity investors, but often by hospitals and health systems who are reflexively installing UCs in repurposed strip malls, sometimes without a clear strategy other than “keeping market share” in an otherwise low margin business.

The reasons for growth, according to the American Academy of Urgent Care? Primarily extended hours (as compared to primary care) and better wait times and lower prices than the ED.

As the private-equity fueled urgent care bubble expands, here’s my prediction on how this all plays out: Don’t bet the farm on UCs being the final answer to the consumer’s search for value. For all of UC’s utility, it’s also possible that urgent care may just get out- maneuvered by the next generation of primary care.

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Will the Real Professor Katherine Baicker Please Stand Up?

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By AL LEWIS and VIK KHANNA 

flying cadeuciiHarvard Professor Katherine Baicker is arguably most acclaimed health policy researcher at arguably the most acclaimed (and not even arguably, the best-endowed) school of public health in the country. Her seminal account of the effect of Medicaid coverage on utilization and health status is a classic. As luck would have it, in 2008 Oregon used a lottery to ration available Medicaid slots. A lottery controls for motivation and as such eliminates participant-non-participant bias, since everyone who enters the lottery wants to participate. That meant only one major variable was in play, which was enrollment in Medicaid or not.

Chance favors the well-prepared, and Professor Baicker jumped on this research windfall. She found that providing Medicaid–and thereby facilitating access to basic preventive medical care–for the previously uninsured did not improve physical health status, but did increase diagnoses and utilization. Because of the soundness of the methodology, the conclusion were unassailable – more access to medical care does not improve outcomes or optimize utilization, which is a proxy for spending. (We ourselves reached a similar conclusion based on a similar analysis on North Carolina Medicaid’s medical home model.)

Yet Professor Baicker herself used exactly the opposite methodology to reach the exact opposite conclusion for workplace wellness.  And that’s where the identity crisis begins.

She and two colleagues published a meta-analysis in 2010 of participant-vs-non-participant workplace wellness programs. Somehow—despite her affinity for Oregon’s lottery control—she found this opposite methodology to be acceptable.  She concluded that workplace wellness generated a very specific two significant-digit 3.27-to-1 ROI from health care claims reduction alone, with another 2.37-to-1 from absenteeism reduction. The title of the article–now celebrating its fifth anniversary as the only work by a well-credentialed author in a prestigious journal ever published in support of wellness ROI—was equally unambiguous:  Workplace Wellness Can Generate Savings.

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Matthew’s end of 2014 charity & issues letter

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By MATTHEW HOLT

I’ve been posting my personal end of year email on THCB for a few years now–here’s 2014’s edition–Matthew Holt

Dec 31 2014: Last year I claimed laziness and failed to write or send out my End of Year Issues email for the first time since I started in 2000. Perhaps it was the stress of being 50, or the fact that despite having 15,000 of my closest friends follow me on Twitter I cant seem to reach people on email, or people miss my Facebook posts. But this year I’ve been guilted back into it by altogether too many people asking me where it was?!

If you don’t know, this is a letter I write mostly to myself about what happened in the year and what I should do about it–mostly in terms of making donations while it’s still 2014. Obviously a few of you like reading it and hopefully one or two of them that does will put their hand into their pocket (or click on the link and use their Paypal account or whatever the electronic equivalent is). And if you don’t like it, well feel free to hit delete, or go onto the next picture of a cat being cute…and I love comments on the blogs/Facebook/Twitter or by email.

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