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All Providers Are Not Equal

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Giving consumers information and data on providers’ quality of care and clinical results is one important path to enhanced transparency, patient engagement, and better health care.     

Two publications out this month add significantly to the dialogue on this issue.  The journal Health Affairs devotes most of its April issue to the theme of “patients’ and consumers’ use of evidence to inform health care decisions.”  And the cover story in the May issue of Consumer Reports is entitled What You Don’t Know About Your Doctor Could Hurt You.  Accompanying that story online is Consumer Reports’ latest ratings of doctors in six states and two metro areas.  

(Disclaimer:  I contributed an article to the April issue of Health Affairs and was involved in one element of the Consumer Reports piece.) 

Among observations in the Health Affairs papers: 

Star-based provider ratings, summarized information (instead of details) and well known signifiers of quality such as blue ribbons work best to compel consumers to both pay attention and make wise choices among health plans and providers.

Getting consumers to consider quality and cost (and the concept of value) remains a challenge.  A survey of some 2,000 people found that most don’t think cost and quality of care are necessarily related.   That’s good and bad.  Good because previously published research indicated that most people leaned to believing that higher price means better quality.   Bad because the new survey signals that people are still disconnected from pursuing value in health care by consciously choosing lower-cost/high-quality providers.   Continue reading…

Are Your Health Cost Savings an Illusion?

flying cadeuciiThe New England Journal of Medicine carried an excellent article by David Casarette, MD, on the topic of health care illusions and medical appropriateness. Click here to read the full article. Hats off to Bob Stauble for a heads up on this article.

Casarette observes that humans have a tendency to see success in what they do, even if in truth there is none. Casarette writes, “Psychologists call this phenomenon, which is based on our tendency to infer causality where none exists, the ‘illusion of control’.” This illusion applies in all walks of life, especially in politics and parenting, and it includes medical care as well.

In medical care, the phenomenon has been referred to as “therapeutic illusion“, and it impacts both doctors and patients. Undoubtedly, therapeutic illusion is why placebos can so effective.

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The C Word

flying cadeuciiThat we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now.  When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.

A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health.  In effect, this view ascribes our very high health costs to moral failure on the part of patients.

Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.

This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.

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Hacking Doctors

flying cadeuciiFor decades and decades we have been counting the number of doctors in America. For decades and decades we have been coming up short compared to other developed nations, and some less developed ones as well. A poorly educated person may be tempted to suggest that we should “make” more doctors. After all, there is hardly a shortage of young people willing and able to undergo the rigors of a medical education. But luckily we are not poorly educated, so we devised much smarter solutions.

If people can’t get a doctor appointment, it must be the doctor’s fault. Hence, we put our foot down and mandated that doctors see people the same day they want to be seen, or shortly thereafter. It sounds great and it worked perfectly for the Veterans Administration (VA), so it should scale terrifically to everybody else.Taking a page from the highly respected Samuel Hahnemann, we decreed that physically “seeing” an actual doctor is not only completely unnecessary, but it may very well be detrimental to the healing process. A doctor effect is created by simply having an MD somewhere in the building, and as technology continues to improve, a virtual doctor presence should do the trick. Some have argued that Mr. Hahnemann’s homeopathic fantasy is no better than a placebo, but we have plenty of research showing that placebos are indeed effective.Continue reading…

Keep Calm and Save the NHS

Keep Calm and Save the NHSIt was Boxing Day weekend. The consultant surgeon summoned the on-call team. “We face a calamity,” he said. The house officer had called in sick. The locum wasn’t going to arrive for another 12 hours. This meant that I, the senior house officer, would have to be the house officer. The registrar would take my place. The consultant, looking tense, would have to be the registrar—i.e. a junior doctor again.

“Junior doctor” is a misnomer because it implies a master and an apprentice. Running the National Health Service (NHS) are apprentices who become Jedis very quickly, and without a Ben Kenobi showing them the ropes.

I’ll never forget my first night on-call in the emergency room (ER). I was one of two junior doctors managing a busy inner city ER in London from midnight to 8 am. Just a year earlier, I was an errant medical student bunking lectures. Now I had to see people with heart attacks, strokes, and broken bones. Seeing the terror on my face, the senior nurse reassured me. “Just look as if you know what you’re doing. We’ll handle the rest.”

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Forget Patient-Facing Apps. Yes, You Read That Correctly.

flying cadeuciiSeveral years ago both Microsoft and Google invested millions of dollars on a flawed assumption: If they built a useful and free healthcare application, people would flock to it. In both cases, the effort failed. At its peak Microsoft HealthVault was only able to enroll a few thousand—largely inactive—users. Google Health was discontinued after a few years.

The problem was (and is) that unlike almost any other business, healthcare is a negative good.

Even if it’s “free,” as was the case with both the Microsoft and Google offerings, most people find tracking their health to be, in some sense, an admission of frailty, imperfection and mortality. Except for occasional blips related more to vanity (weight loss is the prime example), when it comes to our health most of us are in denial. So when people talk about technology for patient engagement, I tend to pause and wonder: Should we be building apps and services just for patients, or for the people who care about them too?

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Big Data? Read the Fine Print

flying cadeuciiAs you think about claims data, the information is capturing the services provided to a patient by a healthcare provider for preventive care or for the diagnosis or the treatment of a condition.

This information can be grouped by different cohorts—those getting preventive exams, those examining categories of care, or those that seeing specific physicians and/or hospitals for conditions. These data, for example, can be grouped by diagnoses, called a diagnosis related group, involving a hospital stay.

However, all claims data is just a collection of medical bills. Medical bills do not contain a complete look at the patient, such as important information as a patient’s prognosis. That’s a gap. Thus, it is important to set appropriate expectations on the use of the data.

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Trump’s Healthcare Plan: Right Diagnosis, Wrong Prescription

Screen Shot 2016-04-08 at 9.37.58 AMDonald Trump recently released a healthcare reform plan. If only he had spent as much time crafting it as he does his hair. 

The GOP frontrunner is right that Obamacare has failed to fix what ails America’s healthcare system. As Trump put it, the Affordable Care Act has “tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices.”  He famously said that he wants to “repeal and replace with something terrific.”

But “terrific” his plan is not.

Take, for instance, his proposal to legalize the importation of “safe and dependable [prescription] drugs from overseas.”

Importing cheaper drugs from other countries may seem like a great way to reduce the cost of medicine for Americans. But there are important reasons why it’s currently prohibited.

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The Prescription for High Drug Costs? Transparency for Starters

Ceci ConnollyFor most Americans, $280,000 might represent the price of a home or perhaps their entire retirement savings. But for the 1.3 million people in this country stricken by rheumatoid arthritis (RA)that quarter million dollars could be their drug bill.

Rheumatoid arthritis is a debilitating disease that causes painful inflammation and swelling of the joints. Left untreated, it can lead to permanent disability. Thankfully medications such as Enbrel, Humira and Zeljanzcan keep patients healthy enough to stay active and keep working. Yet the price tag is quickly becoming out of reach.

One recent report from Express Scripts found that spending on drugs that treat inflammatory conditions such as arthritis rose 25 percent in the last year alone. The annual cost of treating the nation’s RA sufferers is expected to reach $9.3 billion by 2020 – a 45 percent jump from 2013.

For a 45-year-old patient recently diagnosed with RA, the lifetime cost of medication is likely to exceed $1.4 million. Even if that person has 80 percent of their costs covered through insurance, the math works out to $280,000 in copays alone.

There’s something out of kilter when families may be forced to choose between investing in a home or easing a loved one’s pain. Yet that is exactly the sort of Catch-22 some will face if we do not find a sensible way to price drugs.

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