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Category: Hospitals

Healthcare Needs Some IHOPs

By KIM BELLARD

The New York Times had an article that surprised me: Current Job: Award Winning Chef.  Education: IHOP.   The article, by food writer Priya Krishnaprofiled how many high-end chefs credit their training in — gasp! — chain restaurants, such as IHOP, as being invaluable for their success. 

I immediately thought of Atul Gawande’s 2012 article in The New YorkerWhat Big Medicine Can Learn From the Cheesecake Factory.

Ms. Krishna mentions several well-known chefs “who prize the lessons they learned — many as teenagers — in the scaled-up, streamlined world of chain restaurants.”  In addition to IHOP, chefs mentioned experiences at chains such as Applebee’s, California Pizza Kitchen, Chipotle, Hillstone, Houston’s, Howard Johnson’s, Olive Garden, Panda Express, Pappas, Red Lobster, Waffle House, and Wendy’s.  

Some of the lessons learned are instructive.  “It was pretty much that the customer is always right,” one chef mentioned.  Another said she learned “how to be quick, have a good memory, and know the timing of everything.”  A third spoke to the focus that was drilled into all employees: “Hot food hot. Cold food cold. Money to the bank. Clean restrooms,” 

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Guerilla Billing – Missing the Gorilla in the Midst

By ANISH KOKA, MD

No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.

But the problem being experienced by an increasing number of patients is going to a covered (in-network) facility for medical care, and being seen by an out-of-network physician. This happens because not all physicians working in hospitals serve the same master, and thus may not all have agreed to the in-network rate offered by an insurance company.

This is a common occurrence in medicine. At any given time, your local tax-exempt non-profit hospital is out of network of some low paying Medicaid plan or the other.

In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.

Insurers act as proxies for patients when negotiating with the people that actually deliver healthcare – doctors. Largely, the system works to funnel patients to ‘covered’ doctors and hospitals. Patients that walk into an uncovered facility are quickly redirected. But breakdowns happen during emergencies.

There are no choices to make for patients arriving unconscious or in distress to an emergency room. It suddenly becomes very possible to be seen by an out of network physician, and depending on the fine print of the insurance plans selected, some or none of these charges may be covered.

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Primary Care Is at the Center of a Health Revolution

By KEVIN WANG, MD

If our urgent-care-as-healthcare culture isn’t killing us, it’s certainly wasting our time and resources. 

Consider these facts highlighted by Advanced Medical Reviews, based on various studies: 

  • U.S. physicians report that more than 20 percent of overall medical care is not needed.
  • The Congressional Budget Office recently estimated that up to 30 percent of the costs of medical care delivered in the U.S. pay for tests, procedures, doctor visits, hospital stays, and other services that may not actually improve patient health.
  • Unnecessary medical treatment impacts the healthcare industry through decreased physician productivity, increased cost of medical care, and additional work for front office staff and other healthcare professionals.

Most of today’s primary care is, in retail terms, a loss leader — a well-oiled doorway to the wildly expensive sick care system. For decades, practitioners have been forced into production factories, seeing as many patients, ordering as many tests, and sending as many referrals as possible to specialists. Patients, likewise, have avoided going in for regular visits for fear of the price tag attached, often waiting until they’re in such bad shape that urgent (and much more expensive) care is necessary.

The system as it stands isn’t delivering primary care in a way that serves patients, providers, employers, or insurers as well as it could. To improve health at individual and population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it needs to be delivered in a way that doesn’t make patients feel isolated, neglected, or dismissed. 

Luckily, primary care is making a comeback — the kind that doesn’t just treat symptoms, but sees trust, engagement, and behavior change as a path to health.  

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Why Medicare for All Will Not Cure What Ails the Hahnemann

By ASEEM R. SHUKLA, MD

The impending closure of Hahnemann University Hospital is a local tragedy.  Eliminating a 170-year old institution is certain to exaggerate the daily travails of the economically disadvantaged inner-city population that Hahnemann serves as a safety-net hospital.  The closure is also a national tragedy. Hospitals are the towering, visible monuments of our healthcare system, and closings imply that something insidious ails that very system—that all is not well.  

Hospitals are complex entities with varied financial drivers, and the solution is never simple.  And the moment is too rich for politicians who see Hahnemann’s failure as the culmination of their dystopian predictions.  Bernie Sanders, most prominently, stood on the hospital’s doorstep and pitched his deceptively simple solution—Medicare for All.  Medicare for All, Sanders said, would ensure that every patient carries the same coverage, hospitals are paid a predictable rate, and voila, no hospitals need to close.  Private insurance would disappear, and no one would be without coverage.  

Even physicians have jumped on the Medicare for All bandwagon.  Some doctors insist that once profit is removed as a motive for hospital bottom lines, and government bodies decide which hospitals can buy a surgical robot, build a new wing or offer proton beam treatment cancer treatment centers, then all hospitals will do better.  

But these arguments miss a fundamental point: why pitch government insurance for all, like Medicare and Medicaid (a federal and state insurance plan to cover low income adult and children) as a remedy, when it is precisely government-run insurance that is killing Hahnemann and other hospitals in distress? 

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A Patient in the Lobby Refuses to Leave: Medical Emergency, Unhappy Customer or Active Shooter?

By HANS DUVEFELT, MD

The receptionist interrupted me in the middle of my dictation.

“There’s a woman and her husband at the front desk. She’s already been seen by Dr. Kim for chest pain, but refuses to leave and her husband seems really agitated. They’re demanding to speak with you.”

I didn’t take the time to look up the woman’s chart. This could be a medical emergency, I figured. Something may have developed in just the last few minutes.

I hurried down the hall and unlocked the door to the lobby. I had already noticed the man and the woman standing at the glassed-in reception desk.

“I’m Dr. Duvefelt, can I help you?” I began, one hand on the still partway open door behind me.

The husband did the talking.

“My wife just saw Dr. Kim for chest pain and he thought it was nothing. He didn’t have any of her old records, so how could he know?”

While I quickly considered my response, knowing that Dr. Kim is a very thorough and conscientious physician, the man continued:

“Can we get out of here, and step inside for some privacy?”

My mind raced. This was either a medical emergency or an unhappy customer situation. We had the door locks installed not long ago on the advice of the police and many other sources of guidance for clinics like ours. It was a decision made by our Board of Directors. In this age of school, workplace and church shootings, everyone is preparing for such scenarios. We are always reminded not to bring people inside the “secure” areas of our clinics who don’t have an appointment or a true medical emergency.

I figured I had to find out more about this woman’s chest pain in order to make my decision whether to let her inside again; after all, she had just been evaluated.

“Ma’am, are you having chest pain right now?” I asked.

“A little”, she answered.

“How long have you had it?” I probed.

“A couple of years now.”

“And you just saw Dr. Kim?”

“Yes, and he said my EKG looked okay, but he didn’t bother to ask me about you heart valve operation three years ago in, Boston. He just said ’we’ll get those records’, and he told me I was okay today.”

The husband broke in, “It’s the same everywhere we go, everybody just says it’s not a heart attack, but we need more answers than that. we know what it isn’t, but we need to know what it is!” He added, again, “can’t we go inside for some privacy?”

“Have you been seen elsewhere for the same thing?” I said without answering the request.

“Yes, at the emergency room in Concord, New Hampshire when we lived there…”

“Did Dr. Kim have you sign a records release form so we can get the records from Boston and New Hampshire?” I asked.

“Yes”, the woman answered.

“Then that’s all we can do today,” I said. “I hear you telling me this is an ongoing problem, you’ve already been assessed today and Dr. Kim told you that you’re safe today and we’ve requested your old records. That’s what needs to happen.”

“You mean you’re not going to help us today?”

“You’ve seen Dr.Kim, your records will get here, I don’t know what more we can do for you today.”

“You’ll hear about this”, the husband said as they stormed out. Another man in the lobby introduced himself to them and said “I’ll be your witness.”

I closed the self-locking door and wished I had somehow been more skilled and more diplomatic, and I wished the world wasn’t the way it has become in just a few years, with more concern for bolted doors, gun violence and mass shootings than simple customer relations.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

Pulling Care Out of Hospital—By Phone, Ambulance, and Good Ol’ House Calls.

By REBECCA FOGG

In the 20th century, hospitals completed their transformation from the hospice-like institutions of the Middle Ages, into large, gleaming centers of advanced medical expertise and technology that save and improve lives every day. But an unintended consequence of hospitals’ dazzling capabilities is a staggering cost burden that’s proving toxic to the American economy.

Today, hospital care accounts for approximately 33% of the US’ $3.5 trillion annual health care expenditures, according to CMS. The drivers of hospital costs are complex and hard to tackle, including (but not limited to) market consolidation that enables price hikes, heavy administrative burdens, expensive technology and patient usage patterns.

In The Innovator’s Prescription, Clayton Christensen et al. explained another important driver of high hospital care costs: conflation under one roof of business models designed to address very different needs—such as the need for diagnosis of unique, complex conditions and experimental treatments, versus that for highly standardized services (for instance, some surgical procedures). This common phenomenon makes optimization of either business model very difficult, and thus drives up overhead costs.

One solution to this seemingly intractable problem is to make home and community the default locations for care, where in many circumstances it can be provided less expensively, more conveniently, and more effectively than in a hospital. Fortunately, business model innovation toward this end is gaining traction.

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Patients Win When Payers and Providers Speak the Same Language

By CECI CONNOLLY

Discouraging headlines remind us daily of the ugly battles between payers and providers. Fighting for their slice of the $3.5 trillion health care pie, these companies often seem to leave the consumer out of the equation.  But it is not the case across the board. Our latest research documents that when doctors and health plans drop their guards, align incentives and focus on the mutual goal of delivering the best possible care, patients win.

For example, when SelectHealth in Utah partnered with obstetricians and refused to pay for medically unnecessary — often  dangerous — early inductions of labor, procedure rates dropped from 28% to zero, leading to shorter labors, fewer C-sections and $2.5 million in annual savings for all. When Kaiser Foundation Health Plan execs collaborated with Permanente doctors around opioid safety, prescriptions for the often-deadly drugs dropped 40%. And, when Security Health Plan in Wisconsin enlisted physicians and surgeons to develop a new outpatient surgery and rehab center, health outcomes improved; patient satisfaction jumped to 98%; and they saved $4.7 million in the first two years.

These productive partnerships occur in multiple communities across the nation as illustrated in in “Accelerating Adoption of Evidence-Based Care: Payer-Provider Partnerships,” a new report by the Alliance of Community Health Plans. With funding from the Patient-Centered Outcomes Research Institute (PCORI), the 18-month project uncovered five best practices in effective collaboration for health plans:

  1. Build consensus and commitment to change;
  2. Create a team that includes the necessary skill sets, perspectives and staff roles;
  3. Customize education, tools and access to specialized knowledge that the audience needs;
  4. Share timely and accurate data and feedback in a culture of transparency, accountability and healthy competition; and
  5. Align financial investments with clinical and patient experience goals.

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Death by 1000 Clicks Redux

By MARK BRAUNSTEIN, MD

Back in the ‘stone ages’ when I (an MIT grad) was an intern, I was called at 4 AM to see someone else’s gravely ill patient because her IV had infiltrated.  I started a new one and drew some blood work to check on her status.  When the results came back (on paper) I (manually) calculated her anion gap.  This is simple arithmetic but I had been up all night and didn’t do it right.

She died. 

On morning rounds the attending assured me that there was nothing I could have done anyway but, of course, in other circumstances it could have made a difference and an EHR could have easily done this calculation and brought the problematic result to my attention.  My passion for EHRs and FHIR apps to improve them really traces back to this patient episode I will never forget.

My criticism of the recent Kaiser Health News and Fortune article Death by 1000 Clicks is generally not about what it says but what it doesn’t say and its tone.

The article emphasizes the undeniable fact that EHRs cause new sources of medical error that can damage patients. It devotes a lot of ink to documenting some of these in dramatic terms. Yes, with hundreds of vendors out there, the quality of EHR software is highly variable. Among the major weaknesses of some EHRs are awkward user interfaces that can lead to errors. In fact, one of the highlights of my health informatics course is a demonstration of this by a physician whose patient died at least in part as a result of a poor EHR presentation of lab test results.

However, the article fails to pay equal attention to the ways EHRs can, if properly used, help prevent errors. It briefly mentions that around a 60% majority of physicians using EHRs feel that they improve quality. The reasons quality is improved deserved more attention. The article also fails to discuss some of the new, exciting technologies to improve EHR usability through innovative third party apps and he real progress being made in data sharing including patient access to their digital records.

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Innovators Worth Watching: Hennepin Health ACO

By REBECCA FOGG

As U.S. providers continue their slow but steady march away from fee-for-service reimbursement and toward value-based payments, they’re increasingly seeking means of addressing patients’ health-related social needs. That’s because social determinants of health—life circumstances including socioeconomic status, housing, education, and employment—are estimated to have at least twice the impact on risk of premature death than health care. So addressing them is an important part of value-based strategies aiming to improve health while reducing health care costs.

Hennepin Health, a safety-net Accountable Care Organization (ACO) serving Medicaid patients in Minneapolis, Minnesota, is an encouraging example of the trend. Hennepin Health’s ACO is a partnership between the county’s local Human Services and Public Health Department, a local teaching hospital, a Medicaid managed care health plan, and a Federally Qualified Health Center. Its innovative care model is designed to meet the unique needs of the partners’ shared, “high-risk” members, whose complex combination of issues—such as mental illness, addiction, homelessness and/or other hallmarks of social deprivation—often prevent them from accessing or receiving appropriate care through the traditional health system.

The ACO is staffed by an integrated care team comprised of physicians, nurses, pharmacists, social workers and community health workers. Unlike traditional care processes, which often only involve medical assessment, Hennepin Health’s begins with an assessment of members’ social needs, like housing and food insecurity, or lack of transportation and unemployment, so that its care team can tackle those barriers to health in conjunction with members’ medical problems. And throughout members’ care, the team strives to develop and maintain a trusting relationship with members, many of whom have been let down by traditional health care, so that they can continue to identify and assist with more health and social needs over time.

Results thus far has been impressive—according to a Commonwealth Fund case study, the ACO’s medical costs fell an average of 11% per year between 2012 and 2016. And, between 2012 and 2013, its members’ emergency room visits decreased by approximately 9%, with hospital admissions remaining flat and outpatient visits increased by 3.3%. Assuming its results have continued on the same trajectory (we could not find more recent figures), Hennepin Health’s innovative care model shows significant promise.

But does it have the potential to disrupt America’s traditional, episodic, acute care delivery model? We put it to the test with six questions for identifying a Disruptive Innovation.

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Beyond Vaccination: New Measures Needed to Protect Hospitals and the Public Against the Flu

By MARC M. BEUTTLER, MD

Every year at this time, you hear warnings that flu season has arrived. New data from the CDC indicates the season is far from over. So, you are urged by health authorities to get a flu shot. What you may not realize is how the flu can affect the hospitals you and your loved ones rely on for care.  

In January, the large urban hospital where I am an intern faced the worst flu outbreak it has ever seen. Nearly 100 staff members tested positive for the flu. Residents assigned to back-up coverage were called to work daily to supplement the dwindling ranks of the sick. Every hospital visitor was required to wear a mask upon entry. At one point, every patient in the medical ICU had the flu and the whole unit had to be quarantined. Because of this, the hospital was put on diversion – no new patients could be admitted.

Why was this flu outbreak so bad? Doctors are still trying to understand all the causes, but one likely reason is that hospital staff with symptoms came to work and became a reservoir for the virus. A majority of visitors and patients don’t get their flu shots, making matters even worse.

Once administrators caught on to the mess this year’s flu was creating, they took some new and aggressive measures. In addition to the free vaccines provided to employees every year, they performed daily symptom check-ins, encouraged sick days, and held an influenza town hall. After discussion with the State Department of Health, medical residents were provided free Tamiflu and urged to take it as prophylaxis. Only 40% picked it up. Residency directors asked symptomatic house staff to stay home. A positive flu swab meant a mandated five days off work. One month later, we are still required to check in daily and confirm that we are symptom-free via a text messaging system or a checklist circulated to each hospital floor. These responses were effective, and the wave of flu appears to have passed. We must now plan ahead to prevent the next outbreak.

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