Category: Uncategorized

Non-Profit IDNs: Where’s Da Beef?

May 28, 2015• 8

By GREGG MASTERS

I have followed this narrative for quite some time albeit inside the industry contained debate of whether so-called ‘non-profit’ [501(c)3] hospitals or their parent systems (really more aptly characterized as “tax exempt”) actually earn this financial advantage via material ‘returns’ to the communities they serve.

As can be expected you have the party line of the American Hospital Association (AHA) a trade group of predominantly non-profit members vs. that of it’s for-profit brethren The Federation of American Hospitals (FAH). You can guess which side of the argument each of them favor.

Now thanks to a recently published landmark study ‘Integrated Delivery Networks: In Search of Benefits and Market Effects’ by Healthcare Futurist Jeff Goldsmith, PhD et al, of the 501(c)3 cast of characters in the related but more often than not distinctly different ‘IDN culture’ we extend that line of inquiry into what has been a somewhat conversational ‘safe harbor of sorts’ – not any longer?

The Executive Summary notes both the rationale and basis to study the market ‘incident to’ a more focused pricing (via asset concentrations) power line of inquiry:

In January 2014, the National Academy of Social Insurance commissioned a study of the performance of Integrated Delivery Networks (IDNs), incident to its Study Panel on Pricing Power in Health Care Markets. The premise of this analysis was that any examination of the role that hospitals play in health care cost growth is complicated by the fact that in most large markets, the significant hospitals are part of larger, multi-divisional health enterprises. In these markets, hospitals may be part of horizontally integrated hospital systems operating multiple hospitals; vertically integrated health services networks that include physicians, post-acute services and/or health plans; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums) like Kaiser Permanente. The latter two models are collectively labeled IDNs.

Creative Minds: Building a Better Electronic Health Record

May 28, 2015• 4

By Dr. FRANCIS COLLINS

Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.

Still, Chan was troubled by the lack of quantitative evidence Continue reading…

The Smoking Gun: How U.S. Health Care Came to Cost Insanely More

May 27, 2015• 25

By JOE FLOWER

Cost is the big factor. Cost is why we can’t have nice things. The overwhelmingly vast pile of money we siphon into health care in the United States every year is the underlying driver of almost every other problem with health care in the United States from lack of access to waste to fragmentation to poor quality. We can’t afford to fix the problems, cover everyone, do real outreach, build IT systems that are interoperable and transparent and doc-friendly — or so it seems, because at least on weak examination every fix seems to add even more cost. And in the old ways of doing things in health care, the way we have been used to doing business, the conclusion of the weak examination has been correct: Despite the tsunami of money, there is never enough to do it right.

Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

Life Is Complicated

May 27, 2015• 8

By ROB LAMBERTS, MD

“I want to tell you my story now,” a patient recently told me, a woman who suffers from many physical and emotional ailments. She had the diagnosis of PTSD on her problem list, along with hospitalizations for “stress,” but I never asked beyond that.

“OK,” I answered, not knowing what to expect. “Tell me your story.”

She paused for about 30 seconds, but I knew not to interrupt the silence. “I killed my husband,” she finally said.

OK. Unexpected.

She went on to explain a horrible set of circumstances involving alcoholism and physical violence, that resulted in her shooting her husband in self-defense. She spent the two following years on trial for murder, eventually being cleared on all accounts. Despite this, the rifts in her family continue, and she (obviously) still relives this terrible moment.

Deep breath. How can I ever hold any emotional instability against this woman? Who wouldn’t struggle? It brings me back to my oft-repeated mantra: everyone has a backstory.

Not all backstories are so dramatic. One woman, who is very lovely and vibrant from first meeting, revealed that it had been ten years since she was intimate with her husband. She does her best to hide the pain, but the toll of feeling unloved and rejected over ten years has taken a heavy toll. In some ways, her skill at hiding the pain inside causes even more pain, as she faces the daily need to screw up happy emotions she doesn’t have. In her own way, this pernicious pain of rejection has made her walk through life feeling distant from everyone. She smiles to everyone, but the pain doesn’t leave.

How can I know what this is like?

A Shout Out For Our Sponsors: Health Catalyst

May 27, 2015

By MATTHEW HOLT

THCB would literally not exist without the support of our generous sponsors. This blog and the work we do is made possible by the forward-thinking people at companies like HealthCatalyst who have come on board as flagship sponsors. Love THCB? Want to send a message of support? Head over and take a look at what they’re up to for a few minutes. Today’s online boot camp (Health Catalyst Academy) is a great intro. Quality improvement is a tough, bloody fight. Many enter the contest. Not everybody survives. If you’re a hospital administrator, this online boot camp event (Weds 27th 1 PM / archive available) will give you the tools you need to lead successful quality improvement initiatives at your organization and may even make you rethink how you lead data-driven change. If you’re a clinician or healthcare provider involved on the front lines of the quality improvement fight, you’ll come away with an advanced understanding of how data can transform your organization, as well as the role you can play along the way. You can find out more here. Great stuff. — Matthew Holt

Free Our Health Records: Get your health records and help save lives

May 27, 2015• 14

By BOB ROWLEY and DAVID HARLOW

What if a million patients ask for their health records all at once?

Keep in mind that each person would not be submitting a single request. We get our care from multiple health care providers, often across different health systems, with electronic health record systems that don’t really talk to each other. The older we are, the more chronic conditions we have, the greater that number of different providers.

What would the records look like? Where would they go? How would they line up with each other? Request your medical records and find out.

A day of action

The idea of a mass records request has emerged as an assertion of patients’ rights, and in part as a reaction to proposed amendments to Meaningful Use of Certified Electronic Health Records (EHRs) Stage 2 regulations which effectively eliminate patient engagement as a Meaningful Use measure (a measure requiring that at least 5% of patients seen by a provider view, download or transmit their health data in order for the provider to “check the box”).

EHR systems, built to facilitate local (single group, single institution) workflow and reimbursement, aren’t really designed for collaboration beyond the four walls of the local group or institution, or for communication and sharing with patients.

Is Healthcare Designing the Wrong Patient Experience?

May 26, 2015• 3

By CANCER GEEK

Patient experience.

It what’s in. It’s what’s vogue. It’s all the rage.

There is a not a day that one cannot open a paper, a medical journal, Twitter, FaceBook, email, or a conference brochure and not see something about patient experience.

In the U.S. its healthcare’s new version of a best practice. It’s another way to share best practices across an industry. It provides another bandwagon to hop on and spread across the great plains.

But are we scaling mediocrity?

In 1998 Joseph Pine II and James Gilmore wrote a paper published in the Harvard Business Review entitled “The Experience Economy” that was part of a similar book they published by the same title. (paper here)

GOP Has the Fear: King vs. Burwell

May 26, 2015• 1

By JOE FLOWER

Republicans have raged against Obamacare for six years now. But do they really want to see it crash?

We are rapidly approaching the day when the Supreme Court announces its decision in King v. Burwell. The case found a four-word phrase in the 900-page law that says that the tax subsidies are available to people who get insurance through exchanges “established by the state.” Both Republicans and Democrats who actually put the law together, as well as their staffs, say that was a mistake, that no one meant to exclude people on the federal exchange, it is just an artifact of the drafting process that contravenes the whole sense of the law.

The result, if the course found for the plaintiffs, could be rapid and dire: Some 7.5 million would suddenly be paying full freight for healthcare insurance, most would probably stop paying and be force off the plans, and both healthcare and the insurance industry would face a sudden large drop in the revenue streams they need to stay afloat.

But what do Republicans really think?

Doctors Going the Distance (In Education)

May 26, 2015• 2

By EDGAR T. WILSON

We need more doctors.

Between older care providers retiring, and the general population shift that is the aging of the Baby Boomers, we are running into a massive demographic of more, older patients, living longer and managing more chronic conditions. This puts incredible pressure not just on the remaining doctors and nurses to make up the gap, but strains the capacity of schools to recruit, train, and produce competent medical professionals.

So how can schools do more to reach students and empower them to enter the healthcare field?

The increasing popularity of online programs (particularly at the Masters level, among working professionals looking for a boost to their career advancement) has called forth a litany of studies and commentaries questioning everything from their technology to their academics,compared to traditional, on-campus programs. More productive would be questioning the structure and measuring the outcomes of degree programs in general, rather than judging the value of a new delivery mechanism against an alternative more rooted in tradition than science.

In terms of sheer practicality, though, a distance education—yes, even for doctors and surgeons—makes a certain amount of sense. One of the hottest topics in the medical community right now is Electronic Health Records (EHRs) and the ongoing struggle to fully implement and realize the utility of such technology.

Credibility of Evidence: A Reconsideration of the Logic and Strength of Our Healthcare Decisions

May 22, 2015• 4

By ROSS KOPPEL and STEPHEN SOUMERAI

A few days ago, we wrote an editorial for US News and World Reports on the scant or dubious evidence used to support some healthcare policies (the editorial is reproduced in full below). In that case, we focused on studies and CMS statements about a select group of Accountable Care Organizations and their cost savings. Our larger point however is about the need to reconsider the evidence we use for all healthcare-related decisions and policies. We argue that an understanding of research design and the realities of measurement in complex settings should make us both skeptical and humbled. Let’s focus on two consistent distortions.

Evidence-based Medicine (EBM). Few are opposed to evidence-based medicine. What’s the alternative? Ignorance-based medicine? Hunches? However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about 12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients. Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns. This mix of research with the messy reality of medical and hospital practice means that evidence, even if available, is often not fully applicable.

Relative vs. Absolute Drug Efficacy:

Let’s talk a tiny bit about arithmetic. Say we have a medication (called X) that works satisfactorily for 16 out of a hundred cases, i.e., 16% of the time. Not great, but not atypical of many medications. Say then that another drug company has another medication (called “Newbe”) that works satisfactorily 19% of the time. Not a dramatic improvement, but a tad more helpful (ignoring how well it works, how much it costs, and if there are worse side effects). But what does the advertisement for drug “Newbe” say? That “Newbe” is almost 20% better than drug “X.” Honest. And it’s not a total lie. Three percent (the difference between 16% and 19%) is 18.75%, close enough to 20% to make the claim legit. Now, if “Newbe” were advertised as 3% better (but a lot more expensive) sales would probably not skyrocket. But at close to 20% better, who could resist? Continue reading…