Category: Medical Practice

PHYSICIANS/HOPSITALS/INDUSTRY: Customer service: are new market entrants showing the way?

Interesting piece from a marketing consultant called Chris Bevolo from boutique firm GeigerBevolo Inc., in Minneapolis. The report looks at new entrants into health care services and responses to improve the patient experience at Mayo and Park Nicollet.

The new entrants profiled are Steve Case’s Revolution Health, Best Buy’s eq Life ( a pharmacy with manicures while you wait), and MinuteClinics (nurse practitioners in shopping malls). The choice of Revolution Health is a little off, and its attempts (as well as the track record of its advisory board)  has been well slagged off on TCHB and by Joe Paduda before. But the other two are well worthy of a look.

And the message seems to be a) provide shopping while people are waiting to see the doctor as Americans like shopping, and b) do it in Minnesota, because those Minnesotans like innovation. I actually think that Chris has missed a third option which is edutainment while patients are waiting.  But I’ll have more to say about that when I finally get around to discussing Phreesia’s in-office tablet entertainment/patient history service again.

But while I’m more than half-joking, I am full serious. The level of customer service in health care remains abysmal, and whether or not the market forces plans and providers to do something about it sooner rather than later, it surely can’t hurt for them to get out ahead of this trend.

PHARMA/PHYSICIANS: Reimbursements Sway Oncologists’ Drug Choices, by Greg Pawelski

Greg Pawelski is not exactly surprised about the latest revelations about oncologists and their use of chemotherapy.

A joint Michigan/Harvard study confirms that medical oncologists choose cancer chemotherapy based on how much money the chemotherapy earns the medical oncologist. Just published in the journal Health Affairs is a joint Harvard/Michigan study entitled “Does reimbursement influence chemotherapy treatment for cancer patients?” In a study of 9,357 patients, the authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist  This study adds to the ‘smoking gun’ study of Dr. Neil Love on the subject. The results of his survey show that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists prescribed an oral dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel. In contrast, among the community-based oncologists, only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. The existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology. Once a decision to give chemo is taken, physicians receiving more-generous Medicare reimbursements used more-costly treatment regimens.

POLICY/HOSPITALS/PHYSICIANS: Wennberg found wearing concrete boots at bottom of Lake Michigan

No, not really. But Wennberg’s disciples at Dartmouth are coming out with so many uncomfortable facts for the medical-industrial complex that it’s hard to keep count. Starting by introducing the notion of practice variation 30 years ago, the group is now turbo-charging its research production, and basically all of it is bad news for anyone pretending that “American health care is the best in the world”. To paraphrase Uwe Reinhardt, how can the American healthcare not be as good as American health care?

In just the last couple of years not only has the Dartmouth crowd found that care delivered in areas with fewer doctors, and using less advanced technology, leads to better outcomes at lower costs, but they’ve also found that academic medical centers vary threefold in their efficiency of inputs (and costs) to get the same outputs, and most recently that hospital system and location is a better indicator of resource use than population acuity.

And, for the medical establishment, the news gets worse. For the last five or so years, those of us who think that we’ve already got plenty of doctors per head, as we doubled the number in medical school in the 1970s and 1980s and are still waiting for the smaller generations trained in the 1960s to retire, have been drowned out by hysteria from the medical establishment about an impending “physician shortage”. That is of course code for the taxpayer (via Medicare which funds most medical education) to support the creation of new physician residency slots, creating more specialists, who’ll then start applying more medical technology to all of us, which will contribute to more flat of the curve medicine. But I won’t give you a potted Fuchs/Enthoven class here (although you can search around plenty in THCB if you want more).

Today in Health Affairs (or you can read the potted version in Forbes), Dartmouth researcher David Goodman and his team (including Wennberg) cry bullshit on the “we need more doctors” meme. While the big academic centers which get the money from training them would love to have more residents, by examining one type of intensive medical process — caring for patients at the end of life in ICUs — Goodman et al shows pretty logically that many major academic centers use far too many physician resources. In other words we could provide equally good (or probably better) care while using many many fewer physician “inputs”. Hence overall we need fewer physicians, more efficiently used.

Of course any English surgeon, whose workloads and consequently surgical speed massively exceed those of their American counterparts, could have told you that. And my father frequently did every time he came back from a “fact-finding” trip over here. And when Goodman et al invoke the most famous name in American medicine, it’s pretty hard to argue with their conclusions:

"We have benchmarks. We have academic medical centers which are highly successful in terms of the care they provide, and we need to start looking to those places as our examples," Goodman said. "We need to study them and understand them and emulate them. The Mayo Clinic has been studied very extensively and is fairly well-understood," he continued. "We should be at a point where we can emulate some of those systems."

Mayo of course has fantastic outcomes at relatively low cost. In this study it used 8.9 physician full-time equivalents per 1,000 patients in the six months before death, while at the other end of the spectrum New York University Medical Center had 28.3. Of course the system-wide implications of all of the Dartmouth research are too awful for the medical establishment to contemplate, because they in the end mean 20 of the 28.3 doctors at NYU going away – and there are enough cab drivers in New York City as it is. And it’s not just New York city doctors that suffer when you extrapolate:

Applying the Rochester standard to the nation’s elderly, the United States has an excess of physician input; it needs 30,163 fewer FTE inputs than were allocated in 2000. Indeed, the current rate of supply growth along with excess capacity is sufficient to accommodate the 56 percent increase (in the number of elderly-MH add) predicted for 2020, with 49,917 physicians to spare.

All this research of course reminds organized medicine, and the industries that feed off its members prescribing more and more technology without caring about the cost, of something Lenin said back in 1923 about “Better fewer but better”. And you know how the American medical establishment hates them commies. On the other hand, it also invites memories similar to what Maggie Thatcher did to the British steel-workers in 1980 — she basically fired 70% of the workforce, but the amount of steel produced stayed the same. Are they going to call Maggie a commie? I think not, but you may have noticed lots of major industries taking the same approach.

So this research will stay ignored. We spend too much on high-tech medicine, we have too many specialists doing too many heroic procedures, and everyone’s very happy about that. Until that is that we notice that we have a health care system that does a shitty job of basic primary care, doesn’t cover 45 million people and costs way too much.

But if word somehow sneaks out that the two sides of that equation might per chance be related, then the pillars of the medical establishment might choose to move to other tactics. And perhaps the Dartmouth crowd might find themselves wearing concrete boots and hanging with Jimmy Hoffa instead.

CODA: And in a quick reminder that doctors are doctors whatever their
passport cover says, this article explains how spending more on health care in
Canada has not
shortened waiting times

In the five years up to 2002-03, the number of angioplasties (to open
arteries) and bypass surgeries increased 51 per cent, the number of joint
replacements rose 30 per cent, and cataract surgeries 32 per cent. But demand
for care seems to have increased just as much, and it’s not just because the
population is aging. "We’ve got way more activity beyond what the demographics
would dictate," said CIHI Chairman Graham Scott:More research is needed
to understand the phenomenon, he said but new technology is probably a factor.
If there are new tools available, such as MRIs, doctors are likely to use them.
If techniques for a certain kind of surgery improve, the procedure will become
more popular.

Duh! They don’t need more research. When the NHS was introduced in
the UK in 1948, the politicians thought that demand would fall after the initial
rush from those who hadn’t had coverage before wound down. But it didn’t. 50
years of data tells us that in health care supply creates its own demand, and
the way to deal with that is to restrict supply.

PHYSICIANS/TECH: Why diagnostic radiologists won’t make $400K a year forever

One of the smartest observers of the medical scene, UCSF’s Bob Wachter had an interesting article in the NEJM on The Implications of Medical Outsourcing. Here’s the key point:

By severing the connection between the "assay" and its interpretation, digitization allows the assay to be performed by a lower-wage technician at the patient’s bedside and the more cognitively complex interpretation to be performed by a physician who no longer needs to be in the building — or the country.

Of course they’ll be lots of resistance to this — and if anything Wachter understates the extent of the war that’s about to happen (think specialty hospitals). But eventually collaboration software (as being plugged by Microsoft and Nortel) will remove the need for much direct physical connection between patient and physician, and skilled technicians and lower-paid clinicians will mediate between them.

Until of course the availability of lower-paid physical physicians re-disintermediates that trend. If you have no idea what I’m talking about, do yourself a favor and read Eric Schlosser’s fantastic article on why it’s cheaper to hire people than machines to pick strawberries.


Those of you who like your reality dressed up as fiction might like this new book, which Greg Pawelski recommends as telling lots of truth about the oncology-industrial complex.  It’s called A Test of Survival and the web site is worth exploring at least.


POLICY: ACP reccomends UK system

The American College of Physicians is out with its proposals for a better American health care system

The paper recommends voluntary certification and recognition of primary care and specialty medical practices that use health information technology, quality measurement and reporting, patient-friendly scheduling systems and other "best practices" to deliver better value and improve care coordination for patients, especially those with multiple chronic illnesses.While the specific criteria for being listed as a qualified advanced medical home will be developed later, ACP envisions that qualified practices will have the following kinds of services in place.* Primary care physicians would be responsible for partnering with their patients to assure that all of their health care is managed and coordinated effectively. This will be a major improvement from the fragmented health care system that we see today. They would partner with, and educate patients with chronic diseases, like diabetes, to help them manage their own conditions and prevent avoidable complications that would inevitably occur without long-range attention. These complications of diabetes include amputation, blindness, heart attacks and kidney failure.* The practice would use innovative scheduling systems to minimize delays in getting appointments.* Electronic health records and other health information technologies would be used to store all clinical data and test results, which would be immediately available. Physicians in the advanced medical home would use computerized, evidence- based clinical decision guidelines at the point of care to assure that patients get appropriate and recommended care.* Patients would have access to non-urgent medical advice through email and telephone consultations. The practice would have arrangements with a team of consultants and other health care professionals to provide the full spectrum of patient-centered services.

Now I know those physicians are very clever and all that, and I also know that they’re very jealous of how much cash the surgeons and radiologists pull down, but hang on a minute. Haven’t we heard something like this before on THCB? All care managed by PCPs; use of IT to coordinate all care; Choose and Book-type systems for patients; Access for all patients to NHS Direct — they’ve hit on the perfect system. It’s called the UK National Health Service.

Perhaps their members will be slightly less keen when they discover the average income of a GP in the UK, although with the state of the dollar these days it’s not as bad as it used to be if you consider it in American money!

HOSPITALS/PHYSICIANS/POLICY: More data on specialty hospitals suggests the obvious

HSC is out with another study on local markets, and this time it’s looking at specialty hospitals. Not a new tune. HSC finds that purchasers in three local markets where there are plenty of specialty hospitals believe that the hospitals add to overall healthcare costs without improving quality. While purchasers may get lower prices from the new hospitals, they perceive that more procedures are recommended by physicians driving up their number of procedures and therefore overall costs. In addition, traditional community hospitals have been forced to compete by building new facilities, the costs of which get passed onto purchasers in the end, and have been raising their prices for services that specialty hospitals do not offer to compensate for their losses where the specialty hospitals have taken their business.

Yup, it’s all a scam. A war between docs and hospitals with the payers (and the taxpayer) picking up the tab. Of course, as discussed multotimes on THCB, if this was done within the context of some type of fixed budget, then maybe specialty hospitals or teams would be found to be the best way of delivering care. But in a FFS-based cost-unconscious system, they’re just adding to the death of health care affordability by a thousand cuts.

POLICY/PHARMA/PHYSICIANS/POLITICS: Some more publicity about the awful state of pain medication

Finally there is some word getting out about the reign of terror the DEA has been running against pain doctors and its awful impact. This article, called Let’s Get Serious About Relieving Chronic Pain picks up from the NEJM article I wrote about last week. We have known at least since the HHS report in the early 1990s that pain medication is massively under-prescribed. In this article, Jane Brody notes that :

"Pain is a common symptom in patients nearing the end of life," with up to "77 percent of patients suffering unrelieved, pronounced pain during the last year of life," Dr. Timothy J. Moynihan wrote in The Mayo Clinic Proceedings in 2003.

But the news is that the DEA, on its messianic quest to prevent us all going to hell or whatever the theocratic fascists think they’re doing, is not only wasting our time and money, and condemning innocent doctors and patients to prison.  They are also helping most people to suffer in their last year of life. Well I’m sure the DEA think it’s a deal worth taking, but I can’t believe any rational person does. If there’s one government agency that ought to be abolished and have all its employees sent to fill in prairie dog-holes in Nebraska (or wherever), it’s surely the DEA.

PHYSICIANS/POLICY/POLITICS: What else are they going to do?

THCB contributor, radio talk show host and occasional orthopedic surgeon Eric Novack (just kidding, Eric!) sent me this story about the problems that Medicare recipients will  be having getting access to doctors in California if the projected cuts in Medicare reimbursement for Part B actually materialize. So far the cuts for this year have been rescinded by the Senate and the arguing is still going on in the House. Eric has written on THCB recently about the possible bad effects on patient access from cutting physicians fees, and I do agree with him that it’s unjust that only physician fees get cut when hospitals and managed care companies get an increase.

But the problem physicians face is that they don’t really have an alternative. Sure some will retire early, some will move to cash only practices. But given that Medicare is about a third of the money in the system, realistically they can grumble all they like but they’ll end up taking it, and of course doing more things to those patients to make it up on volume.  And that’s not just my opinion, it’s the findings of this five year study by the HSC folks. After all, they went to medical school and residency for all those years, what else are they going to do? There’s only so much room on the poker circuit and only so many of them can run health plans.

That’s why I say that physicians should be figuring out how they collude with government to reduce overall spending while maintaining as good a position as they can. That’s what’s happened in other countries, and one day it’ll happen here. Of course there’s lots of time for gnashing of teeth and entrepreneurial end-arounds before then.

PHYSICIANS/POLICY/POLITICS: Is cutting Medicare Part B fees a good thing? by Eric Novack

THCB’s favorite orthopedic surgeon Eric Novack is grumpy about Medicare’s proposed cuts in physician reimbursement, which are still up in the air as I write. Not sure how much support he’ll get over here on THCB, but it’s ironic that $10 billion is being set aside for health plans and PBMs to reimburse them for possible losses for their role in Medicare Part D, and hospitals are getting a raise. If we are going to cut Medicare, wouldn’t an across the board cut be fairer? Here’s Eric’s thoughts:
Unless Congress acts in the next week, reimbursement to physicians for services provided to Medicare recipients will be cut by 4.4%. The government’s formula for determining the payment rate does not take into account the increasing costs of healthcare delivery. Rather it is based upon such factors as the cost of prescription drugs and general economic factors over which doctors have no control. The reduction is not merely a reduction in the rate of growth of spending. Payments of $100 will become $95.50. And if the Congress’s inaction continues, payment will be less than $75 by 2011. No adjustments for inflation or cost of living are included.
Is all Medicare spending being cut? No, only payments for outpatient services- Medicare Part B- are affected.
Hospital care, paid under Medicare Part A, will get a pay increase of about 4.8%. Managed care plans that get paid by Medicare for managing Medicare HMOs will also get a raise. In both cases, the government’s formula for payment is based upon the medical economic index, which takes into account the costs of health care delivery.
Other than doctors, why should anyone care that reimbursement is going down? What options do patients and physicians have? Doesn’t more affordable mean more accessible?
Nearly 97% of US doctors participate in Medicare. This means that the doctor has signed a contract to accept the rates that the government says it is willing to pay for services. Doctors cannot be selective. They must accept the rate for any and all services that Medicare offers. They cannot tell patients that they will accept the contracted rate for one service, but not another. For example, doctors are not allowed to accept the Medicare rate for knee replacements, but not for hip replacements. This is especially an issue when it comes to the care of very complex conditions, as the level of expertise, time necessary, and potential liability is significantly increased, whereas payment is often only minimally higher than for the care of much simpler cases.
Physicians have several ways to deal with the Medicare cuts. They can retire and stop practicing medicine. Some will. They can see more patients each day, spending less time with each patient. Some will. They can stop practicing medicine and pursue other careers. Some will. They can limit the number of new Medicare patients they will see. Some will. They can drop out of Medicare altogether, requiring Medicare patients to pay completely out of pocket for healthcare services. Some will.
Patients have few, if any, options under the current structure of Medicare. Seniors cannot opt out of Medicare and find private insurance to cover care.
Government fixing of healthcare prices below reasonable market rates will create the medical equivalent of the gasoline crisis of a generation ago. The planned and projected Medicare cuts will have exactly the opposite of the intended effect: seniors throughout the United States will have less access to doctors and healthcare services.


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