Category: Uncategorized

Doctor Paul Revere Fails to Light the Fire

May 13, 2014• 3

By Saurabh Jha, MD

Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

How Community Health Centers are Taking on Accountable Care for the Most Vulnerable

May 12, 2014• 4

By Farzad Mostashari, MD & James Colbert, MD

Like many participants in the Medicare Shared Savings ACO Program (MSSP), Family Health ACO is sailing in uncharted waters.

All ACOs are facing significant challenges in better understanding patient utilization patterns, identifying high-risk patients, and implementing care coordination strategies.

Even more unique is that Family Health ACO (“Family Health”) is composed entirely of federally qualified health centers (FQHCs). FQHCs are community based organizations that provide critical primary and preventive care for millions of underserved and uninsured Americans, regardless of their ability to pay.

Nationwide, there are over 1200 FQHCs serving the health care needs of the working poor, the unemployed, the undocumented, and anyone else in need of primary medical care. Family Health provides care to over 200,000 patients and spans nine counties in New York State; from the bustling streets of New York City to the rural landscapes of the Hudson Valley.

Partners in the Family Health ACO include Open Door Family Medical Centers (“Open Door”), The Institute for Family Health (“The Institute”), and Hudson River Health Care (HRHCare).

Collectively the ACO includes 120 physicians, 60 advanced practice nurses and physician assistants, and nearly 100 dental providers.

These organizations have a strong history of collaboration, including their first venture in 2008 to form the Hudson Information Technology for Community Health (HITCH). HITCH enabled the organizations to pool resources and work collaboratively on cancer screening and diabetes management outreach programs.

The ACO partnership is helping to further strengthen the ties between these three community-based health care organizations and their communities.

A Closer Look at Physician-Hospital Alignment

May 12, 2014• 1

By Paul Keckley

A study by Stanford researchers in the current issue of Health Affairs is likely to intensify growing tension between health insurers and hospitals.

At issue: the impact of physician-hospital consolidation, or vertical integration as some academics prefer to call the trend.

The researchers analyzed 2 million claims submitted to insurers by hospitals from 2001 to 2007, evaluating the impact on hospital prices, volumes (admissions), and spending for privately insured, non-elderly patients. Using data from Truven Analytics MarketScan.

They constructed county-level indices of prices, volumes, and spending and adjusted for enrollees’ age and sex. “We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians.”

What they found is not surprising: vertical integration involving physician-hospital consolidation results in better care and higher costs. They found hospital prices increased 2%-3% each time physician-employing hospitals’ market share increased by one standard deviation. And overall spending on services at the hospitals that employed physicians increased while the utilization of services (volume) at those hospitals didn’t change.

They concluded the following:

“We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians—ownership of physician practices—was associated with higher hospital prices and spending.

We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.”

What’s the significance of the study?

1-Hospitals and physicians will bolster their position that vertical integration is necessary to improved outcomes. The shift from volume to value via accountable care organizations, bundled payments, medical homes, and value based purchasing require closer collaboration between physicians and hospitals.

“Clinical integration” is central to each, and payers– Medicare and private insurers– are promoting these risk-based contracting efforts energetically while cutting reimbursement rates for services aggressively. So the provider position is this: ‘We get better results. We built what you said you wanted.

It’s costly to make the change, especially while since Medicare and Medicaid don’t cover our costs, demand is soaring and our bad debt from the uninsured increasing. You told us to build it, but you don’t want to cover our costs.’

Thinking Out Loud About A New Approach To Digital Health Innovation – PART 3

May 12, 2014

By Jean-Luc Neptune, MD

What Digital Health Innovation Initiatives Did We Pursue at Health 2.0?

In my last post I talked about the many provider- and innovator-facing issues limiting the adoption of digital health technologies in health delivery enterprise settings (e.g. hospitals, physician offices, etc.). As I alluded to in the piece there are some approaches that are working well and one in particular that I think gives us a chance to really accelerate the pace of innovation. In today’s piece I’ll talk about some of these initiatives.

At the Health 2.0 Developer Challenge program we focused on using prize competitions as the primary tool to help health care providers and other stakeholders innovate and effect change at their organizations. Health 2.0, with the support of the Department of Health and Human Services (HHS), Office of the National Coordinator (ONC) and a broad range of for-profit and non-profit partners, pioneered a number of different prize competition formats including – hackathons, challenges, and pilot programs:

Hackathons

A hackathon (what we also called a “code-a-thon”) is an in-person competition event in which developers, designers, technologists, health providers, researchers and others work together closely over a very short period of time (generally 1 to 2 days) to build technology solutions to health care problems. Hackathons are generally focused on a specific theme and center around the utilization of a specific dataset, API (application programming interface), or other technology.

In terms of the potential to help patients and providers the most impactful hackathon project we managed was the “Code-A-Palooza”, a 2-day event that took place as part of the 4th Annual Health Datapalooza (formerly known as the Health Data Initiative Forum). The Code-A-Palooza challenged participants to utilize newly-released Medicare claims data and other data sources to help providers better understand their patient panels from both a clinical and financial perspective. The event generated a number of interesting ideas and prototype applications that had real applicability in the provider setting and could make their way into the clinic with further development. The Code-A-Palooza was successful for a number of reasons, including:

Focus – Our partners at HHS and ONC did a great job in defining a relatively narrow focus for the event and specifying a clear aim – i.e. helping providers develop actionable insights from a very important dataset.
High Value Resource – The Code-A-Palooza gave developers access to a very high value source of information, namely Medicare part A and B claims for 2011, a dataset that had been largely unavailable to the innovator community in the past.
Support – Finally, teams at HHS and ONC provided a high level of support to event participants, including an excellent “pre-game” orientation session, which allowed the attendees to hit the ground running. In addition, a number of participants in the hackathon were physicians, as was one of the event organizers (the ONC’s Rebecca Mitchell), which greatly helped the participants develop insight into real issues faced by providers.

Overall, hackathons are an interesting innovation tool with a great deal of potential, which is why a number of major technology companies, most notably Facebook, use hackathons on a regular basis to stimulate internal innovation and experiment with new ideas. Hackathons can help innovators access the health system and develop a better understanding of relevant health care issues through collaboration with providers sponsoring or participating in an event.

The Doctor Crisis

May 11, 2014• 52

By JACK COCHRAN, MD & CHARLES C. KENNEY

Doctors get blamed a lot these days — blamed for aversion to change, for obstructing innovation, and for being self-centered. This familiar litany asserts that in the nation’s drive to transform health care, physicians are part of the problem.

While it is undeniable that doctors are part of the problem in some places, it is equally undeniable that they are leading innovation in many places and must be part of the solution everywhere.

We may well be in the midst of the most unsettling era in health care and that turbulence is bone-jarring to physicians. We argue that there is a doctor crisis in the United States today – a convergence of complex forces preventing primary care and specialty physicians from doing what they most want to do: Put their patients first at every step in the care process every time.

Barriers include overzealous regulation, bureaucracy, liability burden, reduced reimbursements, and poorly designed care delivery systems.

On the surface the notion of a doctor crisis seems altogether counterintuitive. How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?

But the nature of the crisis emerges quite clearly when we listen to doctors. Ask about the environment in which they practice and you hear words such as “chaos,’’ “conflict,’’ and “dysfunction.’’ Based on deep interviews with doctors throughout the country, the research firm Harris Interactive reports that a majority of physicians are pessimistic about their profession; a profession Harris describes as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’

Have terms this extreme ever been used to characterize the plight of physicians in our nation? Burnout, chaos, conflict, dysfunction, minefield, under assault. How can the nation transform its health care system under such disturbing conditions?

A Modest Proposal: Charting Day

May 10, 2014• 14

By JEFF GOLDSMITH

At the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes ).

The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.

In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem , I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle.

Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.

Physicians, nurses, and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.

Hospitals are solving this problem with a medieval remedy: scribes who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets. Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.

Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.

May 8, 2014• 10

By Mark Graban

In further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.

We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

Would a Single Payer System Be Good for America?

May 8, 2014• 28

By Brian Klepper

On Vox, the vivacious new topical news site, staffed in part by former writers at the Washington Post Wonk Blog, Sarah Kliff writes how Donald Berwick, MD, the recent former Administrator of the Centers for Medicare and Medicaid Services and the Founder of the prestigious Institute for Healthcare Improvement, has concluded that a single payer health system would answer many of the US’ health care woes.

Dr. Berwick is running for Governor of Massachusetts and this is an important plank of his platform. Of course, it is easy to show that single payer systems in other developed nations provide comparable or better quality care at about half the cost that we do in the US.

All else being equal, I might be inclined to agree with Dr. Berwick’s assessment. But the US is special in two ways that make a single payer system unlikely to produce anything but even higher health care costs than we already have.

First, it is very clear that the health care industry dominates our regulatory environment, so that nearlyevery law and rule is spun to the special rather than the common interest. In 2009, the year the ACA was formulated, health care organizations deployed 8 lobbyists for every member of Congress, and contributed an unprecedented $1.2 billion in campaign contributions in exchange for influence over the shape of the law.

This is largely why, while it sets out the path to some important goals, the ACA is so flawed.

Medicare Advantage: Moving toward a Better Model for American Health Care

May 8, 2014• 6

By Robert Pearl, MD

Despite the political angst, the doomsday predictions and a very rocky launch, the Affordable Care Act has enabled more than 8 million Americans to acquire insurance coverage through the public exchanges.

Health insurance increases the probability that patients will access the medical care they need. And my colleagues at Kaiser Permanente are already seeing some positive stories emerging as a result.

They’ve shared dozens of stories with me about patients with undiagnosed medical problems who are now receiving treatment. In particular, I enjoyed hearing about two new patients in Northern California who’ve benefited from being insured.

They came in with life-threatening cancer: One, a mother with a uterine malignancy, and the other, a young man with a testicular mass. Both had gone years without medical care because they were unable to afford it. And now – thanks to medical coverage, early diagnosis and successful treatment – both will live.

But expanding access to health insurance is only the first step. Improving health care delivery is the next step in this journey.With all the acrimony in our nation’s capital, bipartisan agreements are few and far between.

Medicare Advantage may be the one platform on which both parties can stand. Examining this program and why it has proven so successful offers us insights into where we as a nation might choose to go.

Medicare Advantage: A History Born from Necessity

Since the Medicare program was created in 1965, the federal government has been insuring citizens over the age of 65.

This original form of Medicare, called traditional Medicare, was and remains a “fee-for-service” program. That means the Centers for Medicare and Medicaid Services (CMS) – the agency that administers the Medicare program – pays individual physicians for the services they provide to Medicare beneficiaries.

Think of a service as an office visit, a test or a procedure. The price for those services is determined by the agency’s Physician Fee Schedule.

Beginning in 1978, Medicare beneficiaries had a second option. They could enroll in private Health Maintenance Organizations (HMOs) under a “risk contract” between CMS and the HMOs.

A Declaration of Independence Is Only the Beginning

May 7, 2014• 44

By John Haughom, MD

On April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”

Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.

No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.

Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.