Category: Uncategorized

Never Say Never (Events)

Jul 2, 2011• 4

By BOB WACHTER

Earlier this month, the National Quality Forum released its revised list of “Serious Reportable Events in Healthcare, 2011,” with four new events added to the list. While the NQF no longer refers to this list as “Never Events,” it doesn’t really matter, since everyone else does. And this shorthand has helped make this list, which will soon mark its tenth anniversary, a dominant force in the patient safety field.

The NQF was founded in 1999 at the recommendation of Al Gore’s Presidential Advisory Commission on healthcare quality. For its founding chair, the organization selected Ken Kizer, a no-nonsense, seasoned physician-administrator who had just done a spectacular job of transforming the VA system from the subject of scathing articles and movies into a model of high-quality healthcare, a veritable star in patient safety galaxy.

Kizer’s original charge at NQF was to develop a Good Housekeeping seal-equivalent for quality measures (“NQF-endorsed measures”). But soon after he arrived, Kizer added another item to the NQF’s wish list: the creation of a list of medical errors and harm that might ultimately be the subject of a nationwide state-based reporting system. As Kizer said at the time,

This is intended to be a list of things that just should not happen in health care today. For example, operating on the wrong body part [or] a mother dying during childbirth. That’s such a rare event today that it’s generally viewed as something that just shouldn’t happen. Now, there’s probably going to be an occasion now and then when it happens and everything was done right, but it’s so infrequent that it means you have to investigate it every time it occurs. So “never” has quotes around it in this case. Now, wrong-site surgery is a different story—that should never happen. There’s no way that you should take off the right leg when you’re supposed to do the left one. So in this case, never really means never.

Unsurprisingly, the items on the list quickly became known as “Never Events.” Twenty-seven of them were announced in 2002, and the list was expanded and revised four years later. (This primer, written by my colleague Sumant Ranji for our patient safety website, AHRQ Patient Safety Network, is the best description of the list and some of its policy implications.)Continue reading…

Health Care Power Tools for Consumers

Jun 30, 2011• 2

By MARKUS FROMHERZ

Most people are getting their health insurance through their employer. That has been changing slowly, but with healthcare reform, many more people will be left to select their own plans without the pre-selection and help from their employer. What used to be a choice among 3-5 plans is soon to become a selection from dozens of health insurance companies each offering a dozen plans to choose from. And selecting an insurance plan is not like getting car insurance; family makeup, prior health issues, future healthcare needs, and affordability – they all matter. In other words, it’s very personal.

As in other insurance industries, there will be a number of options to help consumers, such as agents and brokers. Cost is one of the most important criteria, but the problem of predicting the impact of plan choices on out-of-pocket costs is much harder, since selecting a plan is such a personal choice. Our needs and therefore expenses also change over time, as we go through different life stages.

As in many industries, there is a lot of data one can harness to help with these decisions. One benefit we see emerging is the availability of personal power tools (similar to financial planning tools) that allow for detailed modeling of an individual or family’s situation. These tools predict likely health care needs and allow one to compare the detailed expenses given different insurance plans. Starting a family? Entering your fifties, with its slew of clinically advised exams? Dealing with the ups and downs of a chronic condition? Those factors can all be taken into account to provide detailed plan options and price comparisons to help choose the optimal health plan.

The Most Commonsensical And Hopeless Reform Idea Ever

Jun 30, 2011• 13

By MICHAEL MILLENSON

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

The PHR School of Hard Knocks

Jun 29, 2011• 38

By MISSY KRASNER

By now everyone has seen the announcement last Friday that Google Health is being formally retired. Thanks to the several years I worked on Google Health, my phone was ringing off the hook Friday afternoon and emails were pouring in all weekend long.

Let me first start by saying that I am not going to comment on any specific company details. I think the broader question to ask anybody that has worked in health IT and consumer tech for the past 15 years is what have you learned from this experience. Or how about, is there a market for PHRs in the future? Given that I started looking at PHRs back in 2005 while I was working for David Brailer at the Office of the National Coordinator (ONC), here is what I would say I have learned:

1. Healthcare is paternalistic – consumers are blind to costs and data.
Let’s face it. Our current healthcare system is set up to be extremely paternalistic. Health plans, hospitals, and physician practices steward patient data on the patient’s behalf. Patients don’t know the costs of a simple outpatient procedure or inpatient stay. Because health care is not a true market-based commodity in this country, patients end up being lousy healthcare consumers. Unlike the banking, airline, and retail industries, this makes it much harder to convince a broad array of consumers to engage in a service that helps them organize, manage, and share their medical records online. The value proposition becomes even harder when consumers are not rewarded with industry aligned incentives for taking the time to manage their personal health data (e.g., discount on health insurance premiums, lower co-pays at doctor office visits, or something beyond a measly $50.00 benefit credit for signing up for a PHR at their place of employment).

Unheard Voices in the Emergency Room

Jun 29, 2011• 6

By NORA O’BRIEN-SURIC

Not too long ago I had the unique experience of needing the services of the emergency room of a major teaching hospital in New York City. (Don’t worry, I’m fine now.) During my thirty-four hours in the ER, I had the opportunity to observe the other patients crowded around on gurneys, in wheelchairs, or in chairs with canes and walkers resting nearby. The ER was overflowing (I was told later that their capacity is 35 and there were about 100 people waiting), and most of the people were older than 60. The doctors and nurses were incredibly busy and were doing their best to provide attention and comfort to everyone. Yet medical care wasn’t all some patients needed. The older people waiting alone needed an advocate. They needed someone to help them understand what the nurses and doctors were telling them and doing to them, someone to reassure them during the long wait to be seen by a doctor and/or to be admitted onto a hospital floor. More than several people were obviously very confused and agitated. They, like me, were waiting for hours, even days until they received care or were admitted to a room. But unlike me, they did not have family there to support them (my fiancé was with me), and they were not able to, or at least did not, verbalize their discomfort and need for food, water, or the bathroom.

After two nights, I was finally admitted to a cardiac surgery floor. I didn’t need cardiac surgery; it was just the only bed available. Every person who entered my room, from aides to meal servers, physical therapists, nurses, and doctors, was surprised to see someone under 60 on their floor. Each of them asked me, “What are you doing here?” I realized that they are so used to working with older people that someone obviously younger than 60 seemed out of place.

This whole episode got me thinking about the training hospital personnel receive in geriatrics. If everyone on the cardiac care unit expected to see a patient older than 60, and if most people in the ER were over 60, then shouldn’t all personnel receive training in geriatrics and care of the elderly? Yes, but this isn’t likely. Most medical schools do not have a geriatric curriculum or rotation, which is why the John A. Hartford Foundation provides grants to schools of medicine, nursing, and social work to help in developing more leaders and curriculum in geriatric education.

Interview with Alexandra Drane: Eliza loads for bear….

Jun 28, 2011• 2

By MATTHEW HOLT

Eliza is one of the more interesting Health 2.0 companies. It’s best known for making millions of automated (and very cute) phone calls on behalf of health insurers, employers and PBMs, but really they have a wealth of collected data that is received from and delivered to consumers over multiple channels to engage them in their health. We’ve featured them at Health 2.0 several times (and FD they’ve been a sponsor), one appearance resulted in them acquiring a fellow panel member (Sprigley) to enhance their web solutions. Like many companies that get to a decent size (somewhere between $25m & $50m in revenues) they faced the choice of getting bought or continuing on with organic growth–which they’ve done so far. Today they’ve made a third choice and taken on private equity money from Parthenon Capital.

What are they going to do with the cash? After all you might guess that there are other tools and services that health plans might be interested in. I interviewed Eliza’s President Alexandra Drane today to find out.

A Field of Dreams?

Jun 28, 2011

By VINCE KURAITIS

A study released last week by the Massachusetts Attorney Generalcontains surprising data to challenge two commonly held ACO (accountable care organization) ”Field of Dreams” assumptions. These assumptions relate to patient ”leakage” — out-of-network patient care and referrals.

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

Particularly for provider systems where hospitals and physicians are jointly at risk for the quality and cost of patients’ care, and have worked together to coordinate and improve care, we would expect to see physicians referring to their partner hospital more often. However, for the two physician-hospital provider systems in Massachusetts with the most years of experience managing referrals for HMO/POS patients under a global payment, one health insurer’s 2009 referral data shows that only 35-45% of adult inpatient care, as measured by revenue, goes to the partner hospital. That percentage can be even lower for providers with little to no experience managing where their patients receive specialist/hospital care, or under plan designs that do not require referrals. [emphasis added]

Continue reading…

Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?

Jun 28, 2011• 35

By KENT BOTTLES, MD

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act.Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.”

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.”

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care – particularly fictitious care – we’ve got a problem. Is this a new quality standard we can expect from our new government health care initiative? Just like scam-artists that phish for unsuspecting people’s financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud – plain and simple.”

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

Secret Shoppers: Needing A Weatherman To Know Which Way The Wind Blows

Jun 28, 2011• 1

By BRIAN KLEPPER

Every now and then, a well-intentioned administration does something relatively harmless but so hare-brained and openly foolish that it takes our breath away. The Obama Administration’s primary care “secret shopper” plan fit this bill, and has already been shelved due to the withering criticism. My inbox a couple days ago was filled with rants by physicians of all political persuasions marveling at the lameness of the idea.

Here’s a short description from Robert Pear’s article in Sunday’s New York Times.

The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

That primary care access has been squeezed is hardly in question. Undervalue a critically important resource, make it a financially undesirable choice for young professionalsand – Voila! – capacity drops. Having too few primary care physicians is the result of 20 years of systematic effort by the specialist-dominated American Medical Association, with the seeming oblivious complicity of both Democratic and Republican administrations.

Ironically, a new study answering a question related to the Administration’s project’s question was released last week. Writing in New England Journal of Medicine, Bisgaier and Rhodes had research assistants pose as mothers trying to make pediatric specialty care appointments, with type of insurance as the only variable. Two-thirds (66%) of those who mentioned Medicaid/CHIP were denied appointments, compared with 11% of those who mentioned private insurance. In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was 22.1 days longer, on average, than for those who said they had private insurance.

Are We Ready for Global Payments?

Jun 28, 2011• 2

By DAVID HARLOW

Massachusetts Attorney General Martha Coakley released her office’s second annual report, An Examination of Health Care Cost Trends and Drivers (PDF; see also press release), which contains a wealth of critical data analysis — and also highlights how little we know about certain things — providing some important context for the discussion of the proposed Part III of Massachusetts health reform, a bill filed by Governor Patrick which would create all-payor ACOs and a system of global payments.

At this late date, few would argue against a move a way from fee-for-service reimbursement for health care, or adding quality metrics to the mix, and tying financial rewards to providers to their performance measured against these metrics. (Consider the Massachusetts Blue Cross Blue Shield ACQ (alternative quality contract) experience.) The AG’s report, however, highlights the wide disparities in payments to providers based on negotiating strength, rather than quality or cost of care (as noted in last year’s AG report; check out the 2009 special commission report, too).