Category: Uncategorized

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.

America’s New Drug War

May 29, 2016• 7

By STEVEN FINDLAY

Screen Shot 2016-05-31 at 6.43.03 AM Earlier this month an 86-year old man in Florida killed his 78-year old wife. He called 911 and when the cops arrived he confessed. When asked why he did it, the man told authorities that the couple could no longer afford her medications. She’d been sick for 15 years, the man said, and was often in pain.

News sources reported that the couple filed for bankruptcy in 2011. At the time, they had $53,900 in liabilities, most in medical bills put on their credit card. They lived primarily on social security.

There’s very likely more to this sad story, and it’s unclear why Medicare didn’t cover most of the couple’s drug costs. He told authorities he shot his wife (while she slept, by the way) because they had “run out of options.”

Related, a few months back a Massachusetts Institute of Technology economist and a Harvard oncologist proposed that banks create a new kind of long-term loan—pegged somewhere between a car loan and a home mortgage—that would let people borrow money to pay for expensive medicines. For example, a loan for a $100,000-a-year drug might require pay back in 9 years at an annual 9% interest rate, they suggested.

With a nod towards value-based payment, they proposed that a borrower would not have to repay a loan if the therapy didn’t work or if the patient died. Andrew Lo, of MIT’s Sloan School of Management, and Dr. David Weinstock, an oncologist at the Dana-Farber Cancer Institute, told news outlets they agreed that good insurance would be a much better option. “This is a private sector stopgap way to deal with [the drug price/cost problem] right now,” said Lo.

How Radiologists Think

May 29, 2016• 11

By SAURABH JHA, MD

flying cadeucii Diagnostic tests such as CAT scans are not perfect. A test can make two errors. It can call a diseased person healthy – a false negative. This is like acquitting a person guilty of a crime. Or a test can falsely call a healthy person diseased – a false positive. This is like convicting an innocent person of a crime that she did not commit. There is a trade-off between false negatives and false positives. To achieve fewer false negatives we incur more false positives.

Physicians do not want to be wrong. Since error is possible we must choose which side to err towards. That is we must choose between two wrongness. We have chosen to reduce false negatives at the expense of false positives. Why this is so is illustrated by screening mammography for breast cancer.

A woman who has cancer which the mammogram picks up is thankful to her physician for picking up the cancer and, plausibly, saving her life.

A woman who does not have cancer and whose mammogram is normal is also thankful to her physician. The doctor does not deserve to be thanked as she played no hand in the absence of the patient’s cancer. But instead of thanking genes or the cosmic lottery, the patient thanks the doctor.

Grading Hospital Report Cards (Again)

May 27, 2016• 3

By MICHAEL MILLENSON

flying cadeucii Medicare recently delayed a plan to issue a simple “star” rating of individual hospitals’ care after 60 senators and 225 House members signed letters supported by major industry groups that questioned Medicare’s methodology.

Rick Pollack, president and chief executive officer of the American Hospital Association (AHA), hailed the hiatus and pledged to make ratings more “useful and helpful for patients.” Perhaps. But while a summary grade for care quality has never fit hospitals—where the orthopedists could have a leg up on competitors, while the cardiac surgeons’ results are disheartening—it’s also true that hospitals have consistently fought attempts at transparency. Over an astonishing stretch of almost 100 years, they’ve done so crudely (burning the results of the first national quality survey in a hotel furnace to keep them from the press), through the courts (suing to prevent release of infection data), and using political clout.

E-mail Liberacion!

May 26, 2016• 3

By JOHN HALAMKA

John Halamka In 2011 and 2012 I wrote about the increasing problem of Business Spam – unsolicited, unconsented advertising that has grown in volume to the point that it constitutes more than half of my email . In 2016, I’ve done an experiment – I’ve not opted in to any newsletter, any website offering notifications or any vendor offering information. I’ve monitored my mailbox for violators of good email practices.

This month, we put a stop to it – cold turkey. Anyone sending business spam is now blocked from the 22,000 users of Beth Israel Deaconess and its affiliates.

Here’s how we did it – using a commercially available appliance we have black listed organizations which send bulk email and companies which violate unsolicited email policies.

A Reality Check on Workplace Wellness

May 25, 2016• 13

By JIM PURCELL

flying cadeucii In 1971, President Nixon declared a war on drugs, and decades later our country’s efforts to battle drug addiction remains largely a failure. Even here on idyllic Cape Cod, we see deaths by overdose and suicide in numbers that are horrifying, particularly with our youngsters. This epidemic shows little sign of abating as communities grapple with the scourge of runaway drug addiction and its gut-wrenching consequences.

So, it’s fair to ask: given our societal failure to stop drug abuse, should we throw in the towel because it’s, as we say here in Massachusetts, wicked hard? Is it acceptable to let drug users spiral downward with predictable ruinous consequences, because to intervene and provide programs that might help could be called invasive or ineffective? Of course not. Because we cannot and will not abandon people with serious health conditions who, on their own, cannot recover.

The workplace and its wellness are not so very different. Today’s American workforce is anything but healthy. Poor health is overwhelmingly the result of unhealthy lifestyles, and it inflicts incredible damage on employers and on employees and their families. It’s a national tragedy, and frankly, it’s a disgrace that we have not had the collective will to do more about it.

Yet, there are those who suggest that we not only give up on trying to improve unhealthy lifestyles, but also that we give up on workplace wellness altogether. I categorically disagree.

The Domino Effect of House v. Burwell

May 24, 2016• 1

By PAUL KECKLEY

Screen Shot 2016-05-24 at 11.50.02 AM

Last week, U.S. District Court of Appeals Judge Rosemary Collyer issued a ruling in House v. Burwell that could cripple the law. In her opinion, the President overstepped his Constitutional authority in granting cost sharing subsidies for those lacking insurance coverage since budgetary approval is required from Congress.

The specific constitutional question is this: Did the administration or specifically the Secretaries of Health and Human Services and Treasury violate Article I, §9, cl 7 of the U.S. Constitution when they “spent public monies that were not appropriated by the Congress.” (United States House of Representatives v. Burwell, 130 F. Supp. 3d 53, 81 D.D.C. 2015). The constitution is explicit:

No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law; and a regular Statement and Account of the Receipts and Expenditures of all public Money shall be published from time to time. (U.S. Const. art. I, § 9, cl. 7.) The courts will have to decide if the portion of the cost sharing subsidies (ACA Sections 1401, 1402) disbursed by the federal government without Congressional authorization violates the law.