Category: Uncategorized

Healthcare Reform’s Missing Link — Nurse Practitioners

Sep 8, 2012• 44

By Patricia Dennehy, RN

Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.

It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.

Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.

Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.

Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.

Breaking News: Health Information Technology Sucks and it Costs too Much

Sep 7, 2012• 57

By Dave Chase

“Established technology is being given a federally funded new lease on life,” athenahealth CEO Jonathan Bush said. “Traditional health software now is on Medicare, being kept alive like grandma.” Bush dubs this program as the “cash for clunkers” program for health IT leaving no doubt what his opinion is regarding the legacy vendors’ solutions.

“I know of no industry where technology is as despised as it is in health care. It’s a statement that it took government money to incentivize healthcare providers to finally do what virtually every other industry has done .”

While one might dismiss Bush’s comments because they are coming from a company with a dog in the fight, the feeling is nearly universal amongst physicians who are the most important users. The best evidence of how abysmal legacy healthIT is, is that the market leader is having trouble getting medical practices to adopt their software even with huge subsidies from large health systems.

In the course of discussions with large health systems, they share their experiences of deployments of a mega Electronic Medical Record (EMR) and how they were offering subsidies to affiliated doctors to adopt the same system. When pressed about how broadly it was being adopted by non-employee physicians (i.e., MDs who have a choice), the penetration was staggeringly low — 0.2% was the average of those who shared figures. This was despite the fact that they were subsidizing 85% of the cost (the maximum allowed by Stark Law).

When I’ve spoken with doctors who have rejected the entreaties from their affiliated health systems, it’s more than the expense (even after a massive subsidy, it’s still several thousand dollars plus monthly costs). Rather, the complexity and lack of user friendliness is the bigger driver. A common statement one hears in healthIT conversations is that doctors hate technology or are afraid of it. Hogwash. They only hate bad technology. Consider the iPad. Doctors are the biggest buyers and it’s not just young doctors.

Flawed Reimbursement Model Leads to Flawed HealthIT

This begs the question, “why is healthIT so bad that massive government and health system subsidies are required to drive adoption?” And how can this possibly be good news? Let me address the issues and then I’ll conclude with the good news. While it may seem easy to bash legacy healthIT vendors, my experience has been that vendors reflect their customers. I would take this a step further. In the case of healthcare, customers reflect the reimbursement model. It’s a reimbursement model that is so broken Americans pay nearly twice as much as other countries to get inferior outcomes.

The Internet’s Downsides: Tell Us Your Stories

Sep 6, 2012• 10

By Susannah Fox

This is a request for help finding people who have had bad experiences with online health resources.

Let me first say that the internet is often a positive force in people’s lives.

My own organization’s research can paint a rather rosy picture: teens are mostly kind to each other online, technology users have more friends than those who stay offline, more people are online than ever before, etc.

But there is another side to the story.

Pew Internet has also documented the fact that, among other groups, people living with disability and those living with chronic health conditions are disproportionately offline. Some people have only dial-up or intermittent access, like at the library or a friend’s house, and therefore miss out on important conversations or information.

The internet can also transmit false or misleading information. A 2010 survey found that 3% of all U.S. adults said they or someone they know has been harmed by following medical advice or health information found online (1% minor, 1% moderate, and 1% serious harm). Thirty percent of adults reported being helped.

There are emotional pitfalls online, too. A 2006 Pew Internet survey found that 10% of people seeking health information online said they felt frightened by the serious or graphic nature of what they found online during their last search.

Are Hospital Business Models on a Burning Platform? Not Yet, But It’s Inevitable.

Sep 6, 2012• 8

By Vince Kuraitis

From reading recent headlines, one might easily get the impression that hospitals are resistant — or at least ambivalent — in their pursuit and adoption of accountable care initiatives.

Are Hospitals Dragging their Feet on Accountable Care?

Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”

KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”

Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”

The Bigger Picture

Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative?

The answer from the headlines above might suggest “no”, but I believe the correct answer is “not yet, but it’s inevitable”. Hospitals are feeling the heat, but it’s just not yet hot enough to jump off the platform and abandon existing business models.

North Carolina Medicaid’s Patient-Centered Medical Home: Lessons Learned

Sep 6, 2012• 15

By Al LEWIS

The ongoing saga of savings estimates for the Community Care of North Carolina (CCNC) patient-centered medical home (PCMH) is finally over. The verdict: no savings. Because the scale and visibility of the CCNC experiment are unparalleled in the Medicaid sector today, it is important that the right policy and delivery system lessons be learned from this dispositive conclusion.

Lesson 1: Enhancements in access do not necessarily create cost reductions, at least in Medicaid.

CCNC is by all accounts an excellent program from the patient’s perspective. Indeed, if I were a Medicaid recipient, I would want to live in North Carolina. The leadership of CCNC is passionate about the program and constantly strives to improve it. However, as was amply observed by J.D. Kleinke on this very blog last week, Medicaid recipients have many lifestyle and economic issues that even the best-intentioned and best-incentivized doctors will never be able to systematically address.

Lesson 2: Perhaps it is time to create an ER co-pay for Medicaid recipients that has more than one digit to the left of the decimal point.

Even as ER co-pays for commercial insurers have soared in the last decade, Medicaid ER co-pays remain virtually non-existent. CCNC created excellent reasons to use primary care but was not permitted to re-price the ER to economically encourage use of primary care. Many Medicaid recipients overuse the ER in part because it is basically free. For the CCNC experiment to truly have a chance to reduce ER visits now that they have created a worthy substitute with their PCMH, it’s only fair to them (and to taxpayers) to reconfigure the financial incentives so that people use their worthy substitute … and then re-measure savings.

Good Business Models and Bad Business Models.

Sep 6, 2012• 8

By J.D. Kleinke

You may have received a refund check in the past few months from your health insurer. This is not your individual reward for staying healthy; it is your insurer’s punishment for making too much money because you did.

Obamacare includes what the health care technocracy calls the “MLR rule” – minimum requirements for medical-loss ratios – or the percentage of premiums collected by health insurers that must be spent on medical care or refunded. The inverse of the MLR is the percentage spent on administration and marketing, and earned as profit. Obamacare sets minimum MLRs of 80 percent for individual and small group plans, and 85 percent for large groups.

Aside from its obvious populist appeal, this profit regulation mechanism signifies a belief, now enshrined in legislation, that health insurance markets do not work. Without such a rule, the architects of Obamacare believe, insurers can name their prices, however inflated, and we all just pay.

In the short term, that is true. Most health insurance plans price only once per year, are subject to long delays in cost trending information and multi-year underwriting cycles, and endure the meddling of a carnival midway’s worth of employee benefits tinkerers, agents, brokers, consultants, and other conflicted middlemen. But in the long term, over multiple annual cycles, premiums do rise and fall, and the health insurance industry’s fortunes with them.

Scaling is Hard. Case Study: athenahealth

Sep 6, 2012

By Jeff Bussgang

There are many companies that are competing to be the “operating system” for small businesses. The theory is that with the advent of the cloud in the digital age, small businesses can leverage a suite of services from a technology vendor to manage all aspects of their work – from payments to record-keeping to marketing to customer communications. Among those competing for this vision are PayPal/eBay, Square and Groupon, with each struggling to pull together pieces of the equation and, importantly, reach the small business in a cost-efficient manner at scale.

One company in Watertown, Massachusetts has been executing on this vision for over a decade with a winning approach for one vertical slice of the small business market: physicians. Although this is not typically how athenahealth is described, it is one way to describe what they are doing that mainstream members of the technology community might understand. I have found it pretty amazing that so few people in the tech community know their story or understand the scale and scope of what they have achieved. That is why I’ve chosen athenahealth for the third in my series on scaling (following Akamai and TripAdvisor).

Founding Story: A Pivot

Athenahealth version 1.0 was a complete failure. The company was originally founded in 1997 by Jonathan Bush (1st cousin of George W.) and Todd Park, a pair of Booz Allen consultants, as a physician practice management company for obstetrics.

Are Organics More Nutritious? Again? Sigh.

Sep 5, 2012• 4

By Marion Nestle

The latest study arguing that organics are not more nutritious than conventionally grown crops once again makes big-time news.

The last time I wrote about a study like this, I posted the British newspaper headlines.

Never mind the media hype. Here’s what the authors conclude:

The published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria.

Isn’t reducing exposure to pesticides and antibiotic use precisely what organic production is supposed to do?
Continue reading…

Economics and Health Systems

Sep 5, 2012• 3

By Conor Green & Chris Hoffmann

Two of the largest healthcare systems in the Twin Cities have announced plans to merge – and if approved it will created the second largest hospital system in Minnesota in terms of revenue (Mayo Clinic is first).

For those non-Midwesterners – the geographical environs of the Twin Cities Metro area comprise a 50 mile circumference anchored by Minneapolis to the west and St. Paul to the east. At a high level, this move essentially links West (Park Nicollet) and East (HealthPartners) and according to news releases from both organizations, the combined health system will include more than 20,000 employees and 1,500 multispecialty physicians. However, there is a more compelling angle to this story.

On the surface the motivation for this move could be primarily economic: The average operating margin for a U.S. hospital is 2.5% — tough financial sledding in a disrupted and crowded market. Overly simplified, the economics of a hospital requires keeping beds full (aka “heads in beds”) … and as hospitals today strive to better align with physicians in order to get more than their fair share of referrals, a range of new business models and ways to engage consumers are emerging in the marketplace.
Continue reading…

Getting the Right Benchmarks For Stroke Care

Sep 5, 2012• 13

By ASHISH JHA, MD

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts. It’s a plain document, mostly in black and white, much of what you might expect from a state government report. Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain. For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home. There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us? That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time. Most of us who study “quality of care” look at that number and think – well, that’s pretty good. It surely could have been worse.

Pretty good? Could have been worse? Take a step back for a moment: if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works? Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home? Is “pretty good” good enough for your loved one?