Category: Uncategorized

An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week

Apr 16, 2013• 34

By Leslie Kernisan, MD

A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.

Now, not everyone believes that a shortfall of PCPs is a serious problem.

However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.

So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.

I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.

Letting the Data Speak: A Fresh Look at Health Care Cost Growth

Apr 16, 2013• 16

By Frank de Libero

In this post I recast the visual display of international health care expenditures. For select OECD countries, this clearly shows the growth of average costs has been moderating while U.S. cost-growth has been accelerating. The graph methodology is discussed along with a caution about marginal thinking. A conjecture is presented as to why the OECD cost-growth is moderating followed by a couple thoughts for action.

What’s Usually Presented
There are many graphs published of international health care expenditures (HCE). Some remind me of multi-colored electric cables strung together, except for one cable that strays from the group. Others are simpler but their message is obscured with chart junk.Continue reading…

Building a Better Health Care System: The Incentive Cure

Apr 15, 2013

By Francois de Brantes

Every day, millions of health care workers wake up and get ready to offer one of the noblest of services – to try and heal and bring comfort to the sick. They do valiant work, day in and day out, even as they confront extrinsic incentives that chip away at their mission and souls.

What are “extrinsic incentives?”

Consider this scenario. You’re driving a year-old car, and the engine light pops on. The car is under full warranty, so you bring it into the dealer. The problem is fixed quickly at no charge. This simple interaction between the buyer and provider of a service illustrates the broader and essential role of extrinsic (external) and intrinsic (internal) incentives.

Intrinsically, most of us want to do the right thing for ourselves, personally and professionally. You want to maintain the car well, so it retains its value and gets you safely from one place to another. The dealer wants to do the best possible job to keep you happy, so you’ll buy from him again. If the car is serviced well and doesn’t need extra repairs, he does well and so do you.

User Fees for Electronic Health Records?

Apr 15, 2013• 8

By Brian Ahier

President Obama has released his 2014 budget proposal, which includes $80.1 billion in spending for theDepartment of Health and Human Services (HHS), an increase of $3.9 billion. The proposed budget for The Office of the National Coordinator for Health IT (ONC) would increase its $61 million budget to $78 million, a 28% increase. The plan also includes a $1 million fee for electronic health record vendors that would almost certainly be passed along to users of the systems.

“In addition to the expanding marketplace and corresponding increase in workload for ONC, much of the work to date has been funded using Recovery Act funds scheduled to expire at the end of FY 2013. Consequently, a new revenue source is necessary to ensure that ONC can continue to fully administer the Certification Program as well as invest resources to improve its efficiency,” the ONC explains in the budget proposal appendix.

In particular, the fee could be used to fund:

Development of implementation guides and other forms of technical assistance for incorporating standards and specifications into products
Development of health IT testing tools that are used by developers, testing laboratories and certification bodies
Development of consensus standards, specifications and policy documents related to health IT certification criteria
Administration of the ONC Health IT Certification Program and maintenance of the Certified Health IT Product List
Post-market surveillance, field testing and monitoring of certified products to ensure they are meeting applicable performance metrics in the clinical environment

Is Patient Engagement the Solution…or a Healthcare Urban Legend?

Apr 14, 2013• 33

By AL LEWIS

The following statistic from the Centers for Disease Control and Prevention (CDC) never fails to shock: the 133-million adults – or “nearly 1 in 2” — with chronic disease account for 75% of spending. Engaging those high utilizers, the story continues, will help bring healthcare spending under control.

This storyline is a classic healthcare urban legend. Essentially nothing in that paragraph makes sense as a matter of policy, or even arithmetic.

Yes, the CDC got their arithmetic wrong. 133-million Americans comprise about 60% of adults, not “nearly 1 in 2.” Second, their definition of “chronic disease” specifically includes stroke, which is a medical event, not a chronic disease, and cancer, many of which would not fit that definition either. (Sloppy editing and arithmetic is a CDC trademark. They also observe that ”almost 1 in 5 youth…has a BMI in or above the 95^th percentile” on their growth chart, which of course is mathematically impossible as written.)

Third, speaking of definitions, how are they defining “chronic disease” so broadly that 60% of us have at least one? Are they counting tooth decay? Dandruff? Ring around the collar?

Corrected or Not, The Statistic Itself Makes No Sense

The statistic is intended to demonstrate that a concentration of costs among people with out-of-control chronic disease but actually shows the opposite. It shows a diffusion of costs, not a concentration. 60% of adults accounting for 75% of spending – or even the incorrect 50% of adults accounting for 75% of spending — is about as far from a 20-80 rule as one can get. Basically costs are not concentrated in ongoing day-to-day chronic disease.

Second, that 75% covers all expenses of that 60%, not just being out of control and needing to go to the hospital, which seems to be the underlying assumption behind the flurry of activity designed to engage these people and control their conditions. Quite the contrary: in many conditions (rare diseases, high blood pressure and asthma come to mind) preventive drugs already overwhelm medical events as a expense category. In a typical commercial or even TANF Medicaid population, only about 10% of hospitalizations are for the five “common chronics” of asthma, diabetes (and its complications), CAD, COPD and heart failure. (In Medicare this percentage and absolute number are much higher – that is indeed a population where control of chronic disease matters.)

Designing the Doctor of the Future

Apr 14, 2013• 20

By Jacob Scott, MD, Ali Ansary, & Sandeep Kishore

At the turn of the 20th century, we built a healthcare system on responding to acute, curative, episodic issues. This system saw the eradication of many diseases and the advent of vaccinations and new treatments. The model was truly developed to be a “sickcare system,” which was what we needed at the time, and saw huge successes.

Fast forward 100 years and Americans are sicker than ever — but with different illnesses. What’s more, there is finally a national consensus that our healthcare system is broken. With increasingly tragic consequences, the reactionary medical paradigm has not provided the preventive care or chronic illness management that our culture needs. Healthcare spending currently consumes 17 percent of our GDP and without a radical shift in thinking, this number may grow even higher.

Sadly, patients are not the only ones suffering. The status quo is breeding a morale crisis among our nation’s doctors. If you asked one of the many thousands of medical students who are just beginning their fall semester why they chose medicine, many of them would give you confused, anxious responses about the field they are entering. This does not bode well for the health of future generations.

Last Spring, we met at TEDMED, an annual “grand gathering” in Washington, DC where forward thinkers from all sectors explore the promise of technology and the potential of human achievement as it pertains to health and medicine. Here, we presented our respective positions. One of us, Ali, argued that new technologies will actively change our health behavior. Another, Sunny, argued that we needed systems thinking in public health, focusing on the causes of the causes. Yet another, Jacob, argued for stopping the “imaginectomies” and fostering creativity in medical training by rethinking selection criteria and curricula for entrance to medical school.

The Economics of Google Glass in Healthcare

Apr 14, 2013• 4

By Kyle Samani

A lot of people think Google Glass can be used as a development platform to create amazing healthcare apps. So do I.

Many of these ideas are relatively obvious, and many of them could be relatively simple to develop. But we won’t see most of them commercialize in the first year Glass is on the market. Maybe even 2 years. Why?

The most obvious analogy to Glass is the iPhone. It’s a revolutionary new technology platform with an incredible new user interface. Glass practically begs the iPhone analogy. Technologically, the analogy has the potential to hold true. But economically, it does not. Because of the economics of Glass, many of these great ideas won’t see the light of day anytime soon.

First, there’s the cost. Glass will run a cool $1500 when it lands in the US this holiday season. The most obvious analogy to Glass is the iPhone. It’s a revolutionary new technology platform with an incredible new user interface. Glass practically begs the iPhone analogy. Technologically, the analogy has the potential to hold true. But economically, it does not. Because of the economics of Glass, many of these great ideas won’t see the light of day anytime soon. There’s no opportunity for a subsidy because Glass doesn’t have native cellular capabilities.

The Story Behind the CommonWell Story

Apr 13, 2013• 5

By John Moore

Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.

What has not been said, or at least has been sensationalized nearly to the point of irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

China’s Ghost Hospitals: A Hard Landing Ahead for China’s Health Care Reforms

Apr 13, 2013• 4

By Damjan Denoble

China is in the midst of a comprehensive $178.3 billion health care reform that is arguably the most ambitious among a series of stalled, largely counterproductive post-1978 efforts to improve access and reduce inequalities between rural and urban areas within China’s regionalized health care system. Unless the health care reforms are accompanied by a reform of fiscal policies, however, the absence of good governance brought on by financial constraints and perverse cadre payment incentives at the sub-national level is likely to undermine efforts to create a robust primary care infrastructure, and will consequently result in reform failure.

The wide-ranging economic reforms of the 1980’s transferred the responsibility for funding health care onto China’s local governments. In areas of China where economic reform resulted in an economic boom – i.e. major coastal cities like Shanghai and the first of the Special Economic Zones in Guangdong and Fujian province – local governments were able to raise enough money from increased tax revenue to greatly counterbalance the withdrawal of Central Government funding. In most of the country, however, Central Government funding decreased while the tax base stayed unchanged or shrunk owing to outward migration to the urban centers and the just mentioned Special Economic Zones.

The Global Cardiovascular Risk Score: A New Performance Measure for Prevention

Apr 12, 2013• 4

By David M. Eddy, MD

Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.

This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.

To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.

While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.