Category: Uncategorized

Fame and Fentanyl

Jun 7, 2016• 1

By KAREN SIBERT, MD

flying cadeucii A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose. Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.

10K Steps + Fitbit

Jun 6, 2016• 5

CECI CONNOLLY

Ceci Connolly Nearly every morning lately, as I make my daily dart to the metro station two blocks away, I pass a familiar face. She is one of about a dozen women who toil in the local nail salon. She does not live in my neighborhood, yet I see her early most mornings hiking up our hill, long before the salon opens.

Most days I wave and smile. But one recent morning I stopped and asked what she was doing. Her English is so-so and my Vietnamese is non-existent. But she managed to proudly convey, “Ten thousand steps!”

She’s not the only one. I myself have caught the walking bug, egged on by my better half and a Fitbit. For me, the rubber wristband has been revelatory. Given how active I am, I just assumed I was getting 10,000 steps every day. Far from it. Knowing your count – and how far you are from the daily goal – is an effective nudge to get off the metro one stop early or choose a lunch spot that’s a few blocks further away.

Sloppy Risk Adjustment and Attribution Guarantee MACRA Won’t Work

Jun 5, 2016• 6

By KIP SULLIVAN

flying cadeucii I just finished reading the 962-page MACRA rule CMS released late in April. I was prepared for the mind-numbing complexity of the document. What I was not prepared for was CMS’s glib treatment of two fundamental issues: The woeful inaccuracy of the scores CMS will use to punish and reward doctors, and the cost to doctors of participating in ACOs, “medical homes” and other “alternative payment models” (APMs)

These are not peripheral issues. If CMS dishes out financial rewards and punishments based on inaccurate data, MACRA will, at best, have no impact on cost and quality and may well have a negative effect. The second problem – the high cost of setting up and running APMs – may not be as lethal as the inaccurate-data problem, but at minimum it will reduce physician participation in APMs and, therefore, the already slim probability that APMs will reduce Medicare costs and improve quality.

In this comment and two more to come, I will review both of these problems and CMS’s what-me-worry attitude toward them. I begin with a jaw-dropping example of CMS’s reckless indifference to its inability to measure physician “merit” accurately.

About Hastert’s “Known Acts:” The Indifference Is As Disturbing as the Crime

Jun 4, 2016• 3

By DAVID INTROCASO

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This past April 8th federal prosecutors made known former Republican House Speaker, Denis Hastert, sexually molested at least four boys while employed as an Illinois high school wrestling coach beginning in the 1960s. Prosecutors said there was “no ambiguity” about these abuses. They were, they said, “known acts.”1 While the news was disturbing sexual and all other forms of child abuse is commonplace. According to the Centers for Disease Control’s (CDC) Adverse Childhood Experiences (ACE) study, one in four girls and one in six boys are sexually assaulted before they reach the age of eighteen.2 It cannot be a surprise therefore that even a member of Congress molested young boys.

Also not surprising is how frequently child abuse, if made known, is not revealed until many years later. Rumors about Hastert’s behavior persisted for years, for example, they were floated during 2006 when Congressman Mark Foley was forced to resign for forwarding soliciting e-mails and sexually suggestive instant messages to teenaged boys. It was not until last year Hastert’s actions nearly fifty years ago became known albeit accidentally. What banking officials and eventually the FBI wanted to learn, pursuant to the PATRIOT Act and other federal laws, was why Hastert made multiple $50,000 bank withdrawals over two years. Hastert initially told officials he was buying vintage cars and stocks. He then explained he did not think banks were safe and then argued he was the victim of extortion. None of these explanations were true. Eventually, the FBI learned Hastert was paying a victim for his silence.

Tech VC Answers ‘Will Computers Replace Doctors’ – I Mean VCs

Jun 4, 2016• 9

By DAVID SHAYWITZ, MD

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A constant frustration for many in healthcare is the cognitive dissonance between the elegant, highly anticipated promise of technology solutions and the messy, lived complexity of clinical practice.

In this context, I was fascinated–and feel compelled to share–this unexpectedly revealing excerpt from a recent (and, as always, captivating) a16z podcast, featuring a conversation a16z founder Marc Andreessen and board partner Balaji Srinivasan recorded at Stanford.

Following an extensive conversation about the factors associated with startup success and VC success, as well as about emerging (or re-, re-emerging) trends such as artificial intelligence (AI), an audience member asked whether AI might not select investments better than actual VCs–a VC version of the “will computers replace doctors?” gauntlet that tech VCs have thrown down before the medical establishment.

What’s the Score?

Jun 3, 2016

By KOFI JONES

flying cadeucii The Congressional Budget Office (CBO) was created in 1974. Its task is to conduct economic analysis of the budget, and, when asked by Congress, to provide fiscal estimates of the potential impact of any given legislative proposal. This is commonly known as “scoring.” Advocates for meaningful and important changes in American domestic policy, even those with major bipartisan and bicameral support, often find themselves running into the CBO wall. If their legislation “scores high,” i.e: will cost public programs money, hopes of passage are quickly dashed.

The challenge is that CBO is bound by rules that don’t allow them to consider the budget in a dynamic way. They can only look at black and white estimates rather than how particular programs might cost money but save money on the other side of the ledger.

Let’s Be Clear About Transparency

Jun 2, 2016• 3

By MICHEL ACCAD, MD

flying cadeucii Transparency—or its absence—continues to fascinate healthcare analysts and healthcare economists. A study just published in the Annals of Internal Medicine addresses the effects of public reporting of hospital mortality rates on outcomes. Its senior author, Dr. Ashish Jha, offered his perspective on the study results and on the topic of transparency in The Health Care Blog.

According to the study investigators, mandatory public reporting of hospital mortality is not improving outcomes. The result of their analysis surprised them because “the notion behind transparency is straightforward” and the “logic [of public reporting] is sound.” The conclusion, therefore, is to persist in the effort, but to do it better with better metrics, better methods, and better data. Says Dr. Jha:

So, the bottom line is this – if transparency is worth doing, why not do it right? Who knows, it might even make care better and create greater trust in the healthcare system.

Now, I have no doubt about the sincere desire of healthcare analysts to improve our lot, but I wonder if they have reflected on a certain pattern that emerges if one studies the history of our healthcare system.

Making Transparency Work: Why We Need New Efforts to Make Data Usable

Jun 1, 2016• 6

By ASHISH JHA, MD

Ashish Jha Get a group of health policy experts together and you’ll find one area of near universal agreement: we need more transparency in healthcare. The notion behind transparency is straightforward; greater availability of data on provider performance helps consumers make better choices and motivates providers to improve. And there is some evidence to suggest it works. In New York State, after cardiac surgery reporting went into effect, some of the worst performing surgeons stopped practicing or moved out of state and overall outcomes improved. But when it comes to hospital care, the impact of transparency has been less clear-cut.

In 2005, Hospital Compare, the national website run by the Centers for Medicare and Medicaid Services (CMS), started publicly reporting hospital performance on process measures – many of which were evidence based (e.g. using aspirin for acute MI patients). By 2008, evidence showed that public reporting had dramatically increased adherence to those process measures, but its impact on patient outcomes was unknown. A few years ago, Andrew Ryan published an excellent paper in Health Affairs examining just that, and found that more than 3 years after Hospital Compare went into effect, there had been no meaningful impact on patient outcomes. Here’s one figure from that paper:

The paper was widely covered in the press — many saw it as a failure of public reporting. Others wondered if it was a failure of Hospital Compare, where the data were difficult to analyze. Some critics shot back that Ryan had only examined the time period when public reporting of process measures was in effect and it would take public reporting of outcomes (i.e. mortality) to actually move the needle on lowering mortality rates. And, in 2009, CMS started doing just that – publicly reporting mortality rates for nearly every hospital in the country. Would it work? Would it actually lead to better outcomes? We didn’t know – and decided to find out.

Fast Medicine

May 31, 2016• 2

By MARC-DAVID MUNK, MD

Screen Shot 2016-05-31 at 9.00.10 AM A diversion into the world of high fashion in this week’s post… It’s an area that everyone who knows me would admit I know nothing about. Nevertheless, here we go…

Martin Schulte, a Partner at Oliver Wyman management consultants, recently posted a fascinating article on, of all things, fashion industry supply chain management. It contains some interesting nuggets for healthcare.

Background: before the 1980’s, couture was customized, reserved for the wealthy, and slow to diffuse into popular culture from biannual fashion shows.

Two disruptive changes shook up the fashion industry in the 1980’s and 1990’s: The first was a move to what is called the “fast-fashion business model” where couture was “translated” from the runways and quickly mass-produced. The second disruption was the emergence of discount realtors like H&M and Topshop, which offered extremely fashion-sensitive clothing (at cut-rate prices) to the masses. These two trends quickly democratized fashion.

Getting Better Outcomes From Outcomes-Based Healthcare

May 31, 2016• 1

By BRYAN OSHIRO

Screen Shot 2016-05-31 at 9.43.38 AM Outcomes-based healthcare is a popular topic of conversation in healthcare today. But despite its popularity, there isn’t a standard outcomes-based healthcare definition. One possible explanation is outcomes-based healthcare’s scope; it encompasses a vast spectrum of strategies used to transition from fee-for-service (FFS) to value-based care.

Although the industry lacks a standard, industry-accepted outcomes-based healthcare definition, there is something healthcare leaders can agree on: health systems need to embrace outcomes-based healthcare in order to survive the transition to value-based care. But healthcare organizations are up against seemingly endless challenges as they attempt to make the switch to this new, value-based approach to care delivery. While many of these organizations are slowly but surely (and successfully) making the transition, just as many feel overwhelmed by the inevitable challenges associated with changing the way they do business.

This article takes a closer look at outcomes-based healthcare and what it really entails. It describes the importance of making the transition, three challenges health systems are up against, and key success factors when it comes to moving away from an FFS model. A Texas Children’s Hospital success story shows these success factors in action and proves that making the transition, although difficult, is not only achievable, but also an absolute necessity.