Tag: evidenced-based medicine

MedEncentive’s Five Year Report

As many involved in the worlds of Health 2.0 and Information Therapy know, some of the most interesting experiments in the world of patient-physician engagement have been happening in the somewhat unlikely environs of small town Oklahoma. There the City of Duncan has put its employees (and their providers) into a system that incents (but doesn’t mandate) physicians to practice according to accepted guidelines, and incents (but doesn’t mandate) patients to read information prescribed by their physicians about their treatments (and tests them about it). The system then asks each party to rate the other.

It sounds simple and frankly, compared to much in health care, it is. The system is supplied by MedEncentive, an Oklahoma City firm led by the charming and engaging Jeff Greene. While I remain fascinated by MedEncentive’s program (and FD MedEncentive has sponsored the Health 2.0 Conference in the past), it’s perhaps grown a little more slowly than Jeff and other fans might have liked—given the scope of the problem.

But the results have been impressive in reducing costs (mostly by reducing hospitalizations) and increasing patient involvement. Yesterday MedEncentive released a five year retrospective. The key finding?:

City of Duncan costs for the most recent year was 8.6% less than five years ago prior to implementing the Program, which is 34.9% less than the projected costs. The resultant four year savings equates to an 8:1 return on investment. (emphasis added)

Jeff abandoned a lucrative business in physician practice management to have a go at this intractable problem. Five years on he deserves plaudits for what he and his team have achieved, and hopefully we’ll see much more innovation like this mushrooming in the future.

Given the relatively lightweight nature of the intervention, I’m amazed that many much larger payers/employers haven’t given it a try. After all, whatever else they’re doing doesn’t seem to be exactly working too well!

Health 2.0 Tools: The power of Twitter

Picture 31

The power of Twitter is real kids, and not for what you think. Used properly Twitter is an information filter. Exhibit A is what happened to the Von Schwebers who run PHARMASurveyor. They were a huge part of the Tools Panel which featured interoperation among 8 members of the Health 2.0 Accelerator at Health 2.0 a couple of weeks back. Then last week they were at an AHRQ conference on Drug Interactions when this happened. Erick von Schweber’s email picks up the story ..

The Chief Medical Officer of Express Scripts is doing his talk, about halfway through, and then tells this rather academic audience of scientists and researchers that there’s something new they need to attend to. It’s called Health 2.0, he says, and he puts up a PowerPoint slide with screen captures from WebMD, HealthVault, Healthline, DoubleCheckMD, etc. Then he tells the audience that the prior week he saw tweets about something new in the space, so he checked it out. He says this is the next major leap ahead in drug safety. So up comes a series of four slides, all screen grabs of PharmaSURVEYOR. And he calls us the Accelerator and explains what we do, disclaiming that he had no knowledge that we’d be there at the conference (I had moderated that morning’s session on making DDI evidence more relevant to patients and physicians; Hansten and Horn were my speakers, the guys who introduced the term “drug interaction” in the mid-sixties). He tells the audience that they must go to PharmaSURVEYOR as well as begin thinking in terms of consumer generated healthcare.

Now it just so happens that the Chief Scientist of Express Scripts but not the Chief Medical Officer had been to Health 2.0 and (I assume) seen the Tools panel demonstrations. But, and this will amaze no one, busy executives at big corporations don’t always immediately communicate all of their learnings with each other. So how did the Chief Medical Officer find out? He probably saw a re-tweet of the #health2con hash tag. That, ladies’n’genelmen, is how our kids is learning these days.

And do you want to see the incredible tools panel from Health 2.0 which contained both the accelerator integration project (in two parts), the debut of Keas, and Eliza showing the first Health 2.0 marriage? Funny you should ask.

Who Should Tell Your MD What to Do?


In this Wall Street Journal op-ed, Norbert Gleicher suggests that expert panels won’t improve health care because the the quality of the research on which they would base their physician practice guidelines is not reliable. Instead, he suggests that our system can self-correct when experts lead us astray. He asserts that we have a “well working free market of ideas in health care, where effective therapies can rise to the surface and win out.”

I’m somewhat sympathetic to Dr. Gleicher’s point about a government-imposed clinical review process, but he overstates the case about a current free market of ideas. Individual insurance companies and Medicare currently make payment decisions with regard to therapeutic judgments every day. How are they informed, and what are their sets of vested interests? Much of that remains hidden from public view.

Meanwhile, too, doctors and hospital practice what Brent James calls “regional medical mythology,” patterns of care divorced from scientific evidence, based as much on the local supply of specialists and what they learned from their predecessors as any other factors.Continue reading…

What Voters Really Think About Evidence-Based Health Care

I want to call your attention to an important survey done by the California-based Campaign for Effective Patient Care. They surveyed California voters on their understanding of evidence-based medicine.The bad news is that patients think their health care treatment is generally evidence-based even though that assumption is highly questionable. The good news is that patients want it to be evidence-based.At a time when we hear anecdotal evidence, particularly from town hall meetings, that people don't want any "interference" between them and their doctors they do seem to appreciate they need to get all of the facts when making a treatment decision.Here is the survey summary. You can access all of it here.

Continue reading…

Op-Ed: The Unintended Consequences of “No Pay for Errors”

Hospital_bedsMedicare’s policy to withhold payment for “never events” – the first effort to use the payment system to promote patient safety – remains intriguing and controversial. To date, most of the discussion has focused on the policy itself at a macro level (including two articles by yours truly, here and here).

In the past month, experts on two of the adverse events on the “no pay” list – hospital falls and catheter-associated urinary tract infections – have chimed in. Interestingly, while agreeing that the overall policy has upsides and risks, they came to strikingly different conclusions about the wisdom of including their pet peril on the list.

Let’s begin with UTIs. Last month’s Annals of Internal Medicine article by Michigan’s Sanjay Saint and colleagues begins, quite cleverly, with a quote from Ben Franklin: “By failing to prepare, you are preparing to fail.” Turns out that among Franklin’s many inventions was the flexible urinary catheter (so who the hell was Foley?). The piece nicely reviews the “no pay” policy and describes the epidemiology of catheter-associated UTI (CAUTI).Continue reading…

Data-Driven Health Care: An Interview with Jerry Reeves, MD

An under-the-radar debate is occurring in health care between those who say data shows that practice variations across the land are “unwarranted” and those who maintain that such variation is inevitable given socioeconomic population differences and cost of practice differences in major metropolitan and rural areas.

  • Data transparency proponents say costs of medical practice, to achieve the same outcomes, should not vary much.
  • Data transparency opponents say data can be shaped to fit a premise that variation is unwarranted, while ignoring the human and economic realities and inherent variability driven by different regional cultures.

That Medicare law forbids doctors to compare fee schedules to avoid monopolitistic behavior, that costs of episodes of care vary greatly with points of patient entry into the system, that third parties generally set physician payments, and that reformers and physicians have fundamentally different economic points of view confounds and complicates the argument.

What follows is an interview with Jerry Reeves, MD, an articulate spokesperson for using data to reduce practice variation, promoting value-based purchasing by payers, and achieving higher levels of physician performance.

In God we trust, all others bring data.”

…..W. Edwards Deming. 1900-1993, American statistician who taught top management how to improve design, product quality, and sales in global markets

“Researchers have estimated nearly 30 percent of Medicine’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas – and those estimates could probably be extrapolated to the health system as a whole.”

…..Statement of Peter Orszag, Director of the Congressional Budget Office, “Opportunities to Increase Efficiencies in Health Care”, June 16, 2008

It is no surprise that the I.T. candidate, Barack Obama, is intent on being the I.T. president. To succeed, he will have to remind his administration early and often, that he is committed to transparency – and that the threat of embarrassment is no justification for secrecy.

“,” New York Times editorial, May 26, 2009



Dr. Reeves is Chief Medical Officer of Hotel Employees and Restaurant Employees International Union (H.E.R.E.I.U.) Welfare Fund. The Fund offers multi-employer health insurance coverage for 90,000 eligible employees and their family members. He is also Principal of Health Innovations LLC which provides health benefits, wellness, and health management consulting services for health plan sponsors and coalitions. He is a Director and Chairman of the Board of Health Insight, the Quality Improvement Organization for Nevada. And he is Medical Director of the Nevada Business Coalition for Health Improvement. Dr. Reeves previously served as Chairman of WorldDoc Inc., Chief Medical Officer of Humana Inc. and Sierra Health Services Inc., and as Chief of Clinical Medicine at USAF Headquarters in Europe. He served two terms on the Board of Health of the State of Nevada and has served on the faculty of three medical schools.


Q: What does Health Innovations do?

Reeves: We work with self-insured employers, Taft-Hartley Trusts, and business coalitions on health to promote programs of transparency and accountability that engage hospitals, doctors and patients in improving their health with a focus on primary and secondary prevention and wellness.  We engage people in more rational lifestyle choices.

Q: And what about your work at HEREIU Welfare Fund, the health plan for Hotel Employees and Restaurant Employees International Union members and their families?

Reeves: We align incentives in the benefit designs of our health insurance coverage  to engage beneficiaries in taking their medications, getting their tests, and seeing the same doctor regularly. We collaborate with doctors, hospitals and utilization management firms to modify behaviors that generate excessive costs and to minimize payments for low value services to achieve better control of costs and outcomes. Much of my work involves analyzing medical and pharmacy claims data and other self reported data reflecting patient risks and provider practice patterns. The findings help us prioritize interventions. We then use ongoing measures to monitor and improve the impacts of our chosen interventions.

Q: You have been doing a study and giving a slide presentation with the title “Variations of Care, Comparisons of more than 450 Episode Treatment Groups – Evaluating Physicians in 4 States.” Tell us about that study, and the 4 states you are talking about.

Reeves: The 4 states are Nevada, Illinois, New York, and Pennsylvania. The study is based on health plan data. We pay medical and pharmacy claims for our members who seek medical services under our health plan. We collect information from those claims and from health risk questionnaires and other biometric measures to track patterns of care.

We can compare plans geographically because we have plans spread across several states.  I can see significant patterns between providers in the same specialty not only in multiple States but also in the same town. They are treating hotel and restaurant workers with many socio-demographic similarities and are paid using similar fee schedules.

The variations in physician preferences are substantial  For high volume episodes in primary care – otitis media, bronchitis, urinary tract infections, or chest pain – the most expensive high volume adult primary care doctor is about 7 to 8 times more expensive per episode than the least expensive doctor in the same specialty within the same town paid on the same fee schedule. The outcomes – no more ear pain, no more cough, no more dysuria, and no more chest pain – are the same.

These variations are not just in the primary care arena.  They exist in the specialty arenas as well – cardiology, ob/gyn, orthopedics. The most expensive cardiologist who takes care of an episode of angina is 5 times as expensive as the least expensive cardiologist; the most expensive orthopedic knee surgeon is on average 2 ½ times more expensive than the least expensive. We see no differences in outcomes.

So there are dramatic differences.  The question is: with health care as expensive as it is already, can we as a country afford to sustain overpayment to outliers who are so much more expensive than their peers in the same town when they are each achieving the same results?

Admittedly there may be variation in the severity of the cases. But we attempt to minimize the impacts of varied illness burden by comparing multiple cases, typically more than 30 cases per doctor. That probably washes out most of the severity related variations. To make things fair, we also take the top 3% and the bottom 3% outliers out of the comparisons to make our estimates more reliable.

Are these variations sustainable in today’s economic environment and in today’s era of global competition?

Q: Are doctors you are comparing aware of what their peers are doing?  Do you send them de-identified information on these variations?

Reeves: We do.  We also sit down with them and share comparative information when we believe we’re using fair measures. In some cases, there’s a reasonable explanation for the variations. For instance, we learned that an outlier orthopedist was known throughout the town as the doctor who did the best job with redoing surgery for patients with failed back surgeries. That likely explained why episode costs were higher for him. We want to learn from them what a rational explanation might be.  Sometimes we get logical valid explanations.  What we notice, though, is that after we’ve had these discussions, the trends move more towards the middle instead of staying at the extremes.

Q: So there’s a swing towards the mean?

Reeves: Yes, there’s a regression towards the mean. The overall system becomes more efficient, and cost trends decrease.

Q: I notice you indicate  variations in total costs of certain episodes of care differ greatly depending on the site of patient entry into the system – the hospital, the ER, an urgent care clinic, or the office.

Reeves: People have known for years that when the first visit is at the hospital, expenses soar.   The typical hospital admission costs 12.7 times as much as an ER visit; an ER visit costs 10.7 times as much as an office visit; a hospitalization costs 136 times as much as an office visit.

When you think about it, you could get a lot more office visits for the cost of one hospital admission or one emergency room visit.  We would rather pay more for patients regularly visiting their continuing care physician than going into the hospital or emergency room.

From our point of view, a patient showing up at the hospital or ER represents a failure of outpatient management. The great majority of all care should be going on between doctor and patient in less restrictive settings and safer environments than hospitals and ERs.

Q: You must offer some educational process informing your members of these cost considerations.

Reeves: We do.  We expend a lot of effort on developing systems to engage our members – posters and brochures, newsletters and explanation of payment (EOP) stuffers, reminders, making available telephonic nurses and health coaches, making it easy for people to call in, making it convenient  to reserve a next day appointment. We show them the comparative out of pocket cost of going to the ER and hospital and explain alternatives that can get their problems solved faster and at less cost.

There is value derived from this approach. For instance, Microsoft has found they can save a lot of money for both the company and the beneficiary if they pay for a doctor to spend an hour at a patient’s home rather than having that patient go to the ER. Also it’s more personal and more likely to lead to a continuous care process that identifies needs earlier.

Also, to align incentives with desired behaviors, we’ve made it much more costly for our members to go the ER rather than seeing their doctor. We also work with our doctors to make sure they have slots available so people can be seen within one business day when they are worried they are getting worse.

It takes two to tango.  We need to engage both the doctor and the patient in improving the availability and affordability of care that improves health. We combine a number of incentives for members and information campaigns about choices resulting in less out of pocket costs, with incentives and interventions with doctors to provide more efficient care.

Q: Do you have data indicating significant cost reductions

Reeves: We do. In Las Vegas, we ran three campaigns: one, to have more patients adhering to their chronic medications; second, a community wide campaign to champion the use of generic drugs; and third, free pharmacies where our people could come to fill prescriptions for generic drugs for chronic conditions with no out-of-pocket expense. Simultaneously, we profiled and gave performance feedback to primary care physicians displaying their apparent adherence to quality of care guidelines and their comparative efficiency expressed in terms of average costs per episode. We used things like ratios of HbA1C testing, microalbuminuria testing, hypertension management, compared to their peers – 22 quality indicators in all. The episode comparisons were for those episodes most common to their specialty with ratios expressed in comparison with the median values among their peers.

We rewarded 155 of those primary care physicians with bonuses and displayed them as Gold Star physician in our provider directory.  At the same time, there were 50 doctors who persistently underperformed despite our sitting down with them and showing them their patterns.  We discontinued our contracts with them for lack of a business reason to continue their contracts. At the same time, we intervened regarding the use of Oxycontin, which was being hugely overused at the time. It turned out that the physicians discontinued from the network had been prescribing more than 50% of the Oxycontin used for our whole population in that town.

The result of our suite of interventions was that out of the $268 million spent the baseline year, we saved $69 million over the next two years according to actuarial projections; our medication adherence for chronic conditions went up 8% even while our drug costs went down dramatically; and our adherence to mammography, Pap smears, and lipid management guidelines improved.

Q: Just to give us perspective, how many people live in Las Vegas and how many doctors are in your network?

Reeves: The total population is about 1.6 million and we had about 1900 doctors in our network then. Our patient base was about 120,000 lives including children then.

Q: Is inpatient cost control a different animal?

Reeves: Inpatient cost control has similar patterns.  We looked at inpatient costs obligated by physicians who sometimes admit patients to hospital in 4 different states – Nevada, Illinois, New York, and Pennsylvania.  In this group, we focused on the inpatient facility costs as part of the overall costs of episodes of care that might result in hospitalization.

When we compared the variance from the expected median inpatient facility costs for various episodes managed by internists, the most expensive internist was $71,000 more expensive than the least expensive internist. The most expensive cardiologist was $203,000 more expensive than the least expensive cardiologist for episodes managed by cardiologists. The discrepancy between the most expensive and least expensive general surgeons was $284,000; and for obstetricians the discrepancy was $305,000.

It appeared that a primary driver for excess cost among obstetricians related to wide variations in the prevalence of primary cesarean section deliveries (among women in their first pregnancy). Among obstetricians delivering more than 200 births per year, we had obstetricians with 54% primary c-section rates and others with 9% primary c-section rates.

It is not defensible or believable that all of these obstetricians can be right. There are some variations that go on that are frankly just plain unsafe. Malpractice insurer underwriters told me they spend much more malpractice insurance payouts for major surgery complications of c-sections than payments for babies who might have fared better from cesarean delivery.

Q: What incentives do you use to encourage doctors to perform better? What are your techniques? You’ve mentioned sitting down with them, showing them data, rewarding them with bonuses. Anything else?

Reeves: We’ve used a suite of multiple interventions.  Doctors deserve multiple opportunities to correct these variations.  It should be three strikes before you’re out.

The most common comment I get back is: “Nobody ever told me this.” “How come nobody has ever said this before?”  It’s a little bit like patients who have previously seen urgent care doctors for quick symptom relief when you tell them they have hypertension or diabetes. They often say, “Nobody ever told me that.” The doctors are right.  Few payers give comparative performance feedback to rank and file physicians.

Essentially once doctors finish their residency program, they are on their own unless they work in a large multispecialty group with internal peer review. By and large in private practice offices, there is not much performance feedback.

Q: So many private practice physicians, if you will, function in a data-vacuum?

Reeves: Exactly.  Once you share the information, they will often point out deficits in the data, even though the data ultimately comes from them.  We are open to challenges and want to continuously improve the quality, accuracy, and reliability of the data.

The first strike is defined by a doctor’s or hospital’s response to reviewing the data so they can internalize it and take action to address the root causes that lead to these variations.

The second strike we may take toward corrective action is sharing the information more widely so that doctors and hospitals understand payers are reluctant to keep paying extra for something that doesn’t result in a superior outcome.  The people paying these bills are hurting, trying to pay their employees and to stay afloat and to compete with other companies. On a larger scale, they are trying to compete with companies in other countries making the same product but not bearing the same costs.  This kind of understanding can sometimes bring accountability and behavior change. We have doctors who call us and ask when they can see their next report. Of course, most of those are performing well and want to disseminate that news.

The third strike is discontinuing contracts with physicians or hospitals that do not alter excessive charging and wasteful practices. Sometimes it may involve discontinuing payment for particular services being overused. For doctors this might mean payers would discontinue payments to a primary care physician who owns a machine for nerve conduction velocity testing or ultrasound imaging who orders dramatically more of these tests per 100 patients compared to their peers who do not own and profit from such equipment. For hospitals, CMS and some other payers have discontinued paying for “Never Events” – high costs incurred as a result of certain hospital acquired conditions like venous thromboembolic events occurring after knee or hip surgery.

Q: As you know, as a nation, we are in the hot heat of the health reform debate, and the Obama administration, particularly Peter Orszag, the budget director, has put a lot of stock in John Wennberg’s work at Dartmouth. Wennberg and his colleagues, using Medicare data, keep emphasizing that most practice variation is “unwarranted,” and the nation could save 30% on total costs by bringing down costs in high spending regions, like some large cities, to those in low spending regions, like the upper Midwest and the South.

But some critics of the Dartmouth studies, like Dr. Richard Cooper, a professor of medicine at Penn and a principal at the Leonard Davis Institute of Health Economics at Penn, have challenged the Dartmouth interpretation of the data in Health Affairs and his blog, www. by saying you can’t compare spending, say in Los Angeles with a 70% Hispanic population, many of whom are poor and sick, with Rochester, Minnesota, with a 90% white population, most of whom are well.

Is your approach similar to the Dartmouth studies on Medicare studies, except that it’s done on a more local level and includes data from commercial insurers on the under 65 population?

Reeves: The Dartmouth and Obama Administration approaches are similar except their focus is mostly on Medicare hospital data.  The end-of-life years are the most expensive by far.  Our data is on hotel and restaurant workers and their families, perhaps more similar to Medicaid patients, but covering a wider spectrum of diseases and conditions. Most of our costs are for prescription drugs and professional services and new technologies.

Even so, our experience is that the overall patterns of practice variation in the commercial world and the Medicare world are parallel. I believe we need to merge the doctor and hospital data from Medicare and Medicaid payments with data available from other commercial payers serving working age populations.  We need to consolidate all that data into common data warehouses.

The data should include not only the professional services of doctors and other clinicians but also the laboratory and diagnostic data,  the inpatient and outpatient facility data, and data on high technology hardware (imaging procedures, implants,) and drugs (biologics, cancer therapies) at least by regions so we can compare these regions against each another. Then adequate sample sizes could become generally available to analyze and display care patterns, technologies, and drugs offering the most value (best outcomes) for the dollars invested.

Q: I just read in the May 22 New York Times a piece entitled “I.B.M. Unveils Software to Process Vast Amounts of Data “for quick analyses of massive chunks of combined data.  Is that what it will take to carry out your vision? Would that be a breakthrough?

Reeves: It would be breakthrough, but I do not see technology as our major challenge.  The challenge is political will. We have a competitive risk issue that leads to carriers not wanting to share their data in a data warehouse for fear that proprietary rates or payments might be revealed or confidentiality agreements that they have negotiated with various providers might be breeched.  Some also worry that personal health information might be revealed.

The banking industry has been able to deal with the issues relating to money for many years and has brought dramatic improvements in efficiency and choice. I remember waiting in long lines to deposit a check on payday. Now I am irritated if it takes an ATM window more than 30 seconds to complete my transaction at a drive through window at midnight. Much of the fear of disclosure of health information is already addressed by HIPAA law and protected by reliable systems of maintaining confidentiality and security.

I cannot emphasize enough how important it is to merge the various data sources into master data files like the Dartmouth Atlas to include physician patterns of care and physician groups’ patterns to enable purchasers, consumers,  and patients to get fairer representation of the choices they have, much like they  do for buying cars and dishwashers.

Q: Are you talking of public disclosure?

Reeves: I would start out with feedback to the providers for their internal quality improvement initiatives and root cause analyses. We do not need to start with public disclosure. But we will need to move down the track of accountability and transparency in order to keep our country afloat because we simply can’t maintain competitive advantage globally with current health care cost trends.

Q: The Dartmouth Group did a study of five major academic centers – Mayo, UCLA, the Cleveland Clinic, NYU, and Hopkins – and it showed a significant variation in costs.

Reeves: That’s absolutely true, and I see the same thing happening in our domains. Take our data in Chicago and Pittsburgh.  We can rank order costs in hospitals in those cities by diagnostic group, and the most expensive hospital may often be 5 to 8 times as expensive as the least expensive hospital with the same outcomes for patients with apparently similar risk and case mix.

Q: Is it realistic to believe we can homogenize these cost differences across the country, given the different institutional, regional, and cultural differences?  After all, there are different expenses and profits required in New York City and rural Alabama.

Reeves: I don’t know we can do that, but I think we can compare rural Alabama to rural Georgia. And we can compare Chicago to New York. What’s right is right.

The right way to practice family practice is the right way the world around.  The right way to practice internal medicine is the right way the world around. It is both feasible and advisable to decrease the incredible discrepancies between good and bad practices of medicine in our country and elsewhere.

Yes, there are culture differences, and there are habits and preferences that vary from location to location.  For example, we have more problems with back surgeries and re-dos and excessive narcotic use in places like Las Vegas than in New York.  And we have a lot bigger problem with obesity and bariatric surgery in West Virginia than in Chicago.

There are variations driven by demographics, socioeconomics, and patterns of living. But when it comes to delivering effective, efficient care, 800% differences are not defensible.  If you have two cars that drive the same speed, look similar, and last the same thousands of miles, and one is eight times more expensive than the other, how many people would buy the more expensive car at the 700% higher cost?

If you apply that same principle to health care, how long do we really believe we can sustain this kind of variation and turn a blind eye to it? It doesn’t seem like a reasonable proposition to me.

Q: Do you think the Obama administration’s proposal to create a National Comparative Effectiveness Institute would address these issues?

Reeves: It would simply be an extension of what’s going on already.  A number of organizations have been doing comparisons of relative therapeutic effectiveness and cost efficiency of new technologies and drugs for years. They have graded the scientific evidence for level of proof of what works best, cost effectiveness, and safety. Managed care plans and carriers have been using these rank order grades to help them decide what their insurance plans are going to cover.  We already have a long history of comparative effectiveness studies.  For instance, the Medical Letter does this kind of thing for drugs, and looks in a nonbiased way at outcomes and costs. Do we really need more “me too” drugs and expensive images that don’t change care effectiveness and outcomes commensurate with their costs? I sometimes think new technologies are developed mostly because it’s possible, then the developers go looking for problems the technology might help. Can we really afford that? Who should pay for all of that? Under what special circumstances should society as a whole pay for that?

I think in the future we will see the rank ordering of ratings of various health care services much like in Consumer Reports. The day of secrecy and behind the scenes behaviors hidden to the public will eventually be coming to an end.  There are multiple initiatives going on in state legislatures, business coalitions, and other organizations that are collecting comparative effectiveness data and displaying them to the public.  For instance, you have the Leapfrog measures of safety, and the Institute for Healthcare Improvement’s 5 Million Lives campaign and the publicly displayed CMS core measures of hospital performance.  You have publicly available data bases of Medicare claims payments in most States and all payer data bases in 17 states comparing hospitals’ data to that of competitors in the same market. And the National Business Coalition on Health and some States are collecting data comparing health plans to each other and displaying performance metrics on public websites. It’s all about transparency and accountability. Congress has a track record of strongly favoring this approach.

Q: And yet, despites all these rankings and initiatives and talk of transparency and accountability and nearly 40 years after Wennberg’s original paper on Medicare practice variation, the variations remain high.

Reeves: They do, but progress is occurring.   Over a 3 year period in Las Vegas, we’ve been giving quarterly reports to hospitals comparing their Leapfrog results, patient satisfaction results, and  CMS core measure national percentile rankings to those of their Las Vegas hospital peers. At the beginning, the rankings ranged from the 88th percentile for one hospital to 2nd percentile rank for another.

After regular meetings with senior executives of these hospitals, discussing their quality improvement initiatives, the hospital at the 2nd percentile moved up to the 38th percentile nationally at the end of the 3rd year. So substantial improvement is possible through transparency.  Even more improvement is possible through incentives such as bonuses, as demonstrated by the Premier Project with CMS, in which hospitals received 2% more in payments for meeting quality standards. Those hospitals participating in the Pay for Performance cohort showed substantially more improvements than those subjected only to public reporting.

Value-based design of CMS and private health plan coverage works. They decrease out of pocket costs for high value services and treatments and may raise the out of pocket costs for interventions with marginal effectiveness and value. Cost trends bend downward, and value and quality go up. They have to, if this country is going to survive in a competitive world economy.

Along with 4 large company CEOs, a large company benefits manager, and a State health officer, I met recently with President Obama in the White House. This was the day after his historic meeting with national health leaders – the AHA, the AMA, America’s health Insurance Plans, PharMa, the Service Employees International Union, and others – who pledged to reduce national health care spending by $2 trillion over the next decade.  Our roles were to explain our interventions that have lowered cost trends and improved health outcomes so they could be adopted for federal employees and other Americans. President Obama and his administration are determined to reform the system to achieve lower cost trends and better health status for Americans.  It will take insurance plan designs that align incentives with desired behaviors, and data based reporting of impacts of  positive and negative incentives that engage physicians and patients more actively for this effort to succeed. Working together, we can do a lot better than we have the past several years.


The interviewer is Richard L. Reece, MD, author of Innovation-Driven Health Care: 34 Keys to Transformation (Jones and Bartlett, 2007), Obama, Doctors, and Health Reform; A Doctor Assesses Odds for Success (Universe, 2009), and blogger,

Thomas Kuhn, Health Care Reform and Vascular Disease

The puzzle of improving care and reducing costs in American medicine and in vascular conditions (that is, diseases associated with blood vessel metabolism) in particular – these are responsible for 60 percent of all cost – has been in part due to the nature of medicine itself.  Physicians are at their core scientists. Our undergraduate degrees are in the scientific disciplines of biology, chemistry, physics. We have been educated in the culture of science and that is the environment in which we practice.

Thomas Kuhn’s The Structure of Scientific Revolutions perfectly describes a central problem in cardiovascular diseases.  A scientific community cannot practice without a set of core beliefs. These central constructs are, in Kuhn’s terms, the foundation of the “educational initiation that prepares and licenses the student for professional practice.” The student’s instruction is “rigorous and rigid,” with the purpose of ensuring that these beliefs are firmly fixed in the student’s mind.

Scientists go to great lengths to defend the idea that they know what the world is like. It should come as no surprise then that “normal science,” – that is, the framework to explain the world used by the scientists who lead the current paradigm – will often suppress novelties that undermine its foundations.

So research often is not about discovering the unknown, but rather “a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education.” A generally-accepted paradigm, essential to effective scientific investigation, requires “some implicit body of intertwined theoretical and methodological belief that permits selection, evaluation and criticism.” That paradigm, in turn, forms the basis of a new profession or specialty, like Interventional Cardiology, and from this follows the establishment of journals, societies, and a special place in the medical academic structure.  The articles in those journals are intended for professional colleagues who share the the field’s knowledge and who are the only ones capable of fully understanding them.

A shift in the accepted scientific construct occurs when research aimed at further developing that formulation of the evidence runs into an anomaly — a fact that does not fit the paradigm and cannot be explained away. When anomalies pop up, they typically are not welcome and may be ignored. The current paradigm’s scientists may make little or no effort to formulate a new theory to explain the phenomenon. They are also likely to be intolerant of practitioners who try to do so.

All the same, the discovery of anomaly is the stimulus that leads to a new paradigm. The failure of  existing beliefs and rules is the necessary but insufficient platform for the development of new scientific and practice structure.

The leaders of an entrenched paradigm strongly resist alternate systems of science and practice. Only in  crisis can that resistance be overcome. No better example of this can be found than the current situation in the treatment of cardiovascular and arterial disease.


The fixed blockage is the dominant paradigm today for both the science and practice of cardiovascular and arterial disease management. In other words, it is viewed as a plumbing problem. This paradigm has persisted because it made so much sense.

Angina is a historical diagnosis – particularly in a man.  Just talk to the patient and you can make the diagnosis. If a man walks and gets chest pain that is relieved by rest, he has angina. Almost all of those men have a blockage of 70% or greater.

If the cardiologist does a catheterization he will demonstrate the blockage.  If he opens the blockage with a stent the pain will go away.  But many men with angina go on to have heart attacks – it is high risk.  So it is no surprise that blockage became the dominant scientific paradigm. To this day, virtually the entirety of the science, practice, and financing are organized around this idea: Heart attacks are caused by a progressive blockage. If we open that blockage before it becomes complete, we will save the patient.

Now the anomaly. In 1988, WC Little and his colleagues at Wake Forest performed a study “to help determine if coronary angiography can predict the site of a future coronary occlusion.” If the plumbing model were correct and a progressive blockage of the artery caused myocardial infarction, the findings on coronary angiography should predict the site of heart attack. It did not.

Little and his colleagues studied 42 consecutive patient records of patients who had had coronary angiography before and up to a month after having a heart attack. In 19 of 29 (66%) patients, the artery that occluded subsequently had less than a 50% occlusion on the first angiogram. In 28 of 29 (97%) the stenosis (or narrowing of the vessel) was less than 70%, even though it takes a stenosis of 70% or greater to justify angioplasty with stenting.

Little concluded

“Because it was difficult to predict the site of subsequent occlusion in our patients from the initial coronary angiogram, coronary bypass surgery or angioplasty appropriately directed only at the angiographically significant lesions initially present in almost all of our patients would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”

And, in keeping with Kuhn’s description of the scientific revolution, the best arterial disease scientists quickly developed a new paradigm that provides a much better explanation of the mechanism of heart attack and other vascular events. Within 7 years of the first anomaly, Erling Falk, Prediman K Shah and Valentin Fuster, leading academic cardiologists, summarized four studies that came to the same conclusion as Little. Only 14% of heart attacks occur in an artery that was 70% blocked on the previous catheterization. Only 14% of heart attacks occurred in an artery with enough obstruction to cause angina and justify bypass surgery or stenting.  Falk and his colleagues described the new paradigm very simply:

“plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”

Peter Libby is Chief of Cardiology at Boston’s Brigham and Women’s Hospital, one of Harvard’s teaching hospitals. One of the world’s foremost authorities on the science of heart attack and plaque rupture, he quite literally “wrote the book” on the topic. In the volume of Harrison’s Principles of Internal Medicine, the standard reference text for the discipline, that sits on my desk, Peter Libby wrote the chapter entitled The Pathogenesis of Atherosclerosis.

In 1995, the same year as the Falk article, Libby wrote a piece called “The Molecular Basis of the Acute Coronary Syndromes.”

“Bypass surgery or transluminal angioplasty (dilation of the artery and then, propping it open with stents) provide rational and often effective therapies for these fixed, high-grade stenoses (blockages).  However, these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot).  It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment aimed at severe stenoses does not prevent myocardial infarction. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”

In other words, heart attack is not caused by a gradual narrowing of the artery, but rather is the result of sudden cholesterol plaque rupture with subsequent clot formation, which blocks off the artery and cuts off blood flow.

Today, 14 years later, we can dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose.  We can prevent clot formation with aspirin and other medications.

The scientific revolution in vascular disease is 20 years old and the new paradigm firmly in place and supported by the very best vascular scientists. Still, the practice paradigm persists as if the science never changed.

Just last year, I heard a brilliant talk by Valentin Fuster, one of the co-authors on the Falk article. Afterward I asked him what it would take to move the practice paradigm forward. He responded that it would take the time required to replace current practitioners wi
th the next generation.

Can we afford to wait for that?  Several years ago, I heard Dr Libby speak at a national meeting of the American Society of Hypertension. I later asked him, “Dr Libby, I read your article from 1995, saying that bypass and stenting do not prevent heart attack, do you still hold that view.”  He became very animated and enthusiastic and said he was convinced that the new science was valid and required action to move it forward.

The science has become irrefutable.  Yet the defenders of the old science still carry the day.  I fear that medical scientists will not move this forward and it will require changes in payment and support for research coming from outside the professional community to bring the latest science to patients.

We have to recognize the suppression of anomalies and new paradigms in medicine. Only then can we develop mechanisms that can bring the latest evidence-based science to patients.

Bill Bestermann is Medical Director, Integrated Health Services at Holston Medical Group in Kingsport, TN.

Following the Science To A New Era In Medicine

By WILLIAM BESTERMANN, MD6a00d8341c909d53ef010536ee8138970b-pi

“The current care systems cannot do the job.  Trying harder will not work.  Changing systems of care will.”

Crossing the Quality Chasm, Institute of Medicine, 2001

Medical leadership in the United States has not yet come to grips with the level of structural and systemic change that will be required to produce the dramatic improvements in the management of chronic conditions that are required to reduce disability and mortality while reducing costs.

In this same space, I recently published an article called “The New Science of Vascular Disease.” The take-away message of that article is this: one of the most important products of our medical system is optimal medical therapy for vascular risk factors. As a system, we don’t even come close to achieving conservative goals for global risk management and the latest work from Dr. Steven Nissen tells us that plaque progresses more rapidly when the LDL cholesterol is over 70 and the systolic blood pressure is 120. Most providers are not even shooting at those targets.

The objective observer today could make a better case that medical rather than military intelligence was an oxymoron. The US military and medical systems share many common features. The scientific and industrial revolutions have changed both endeavors at a pace that can barely be digested. The tools that we use have improved dramatically and properly applied can achieve results that were unthinkable 100 years ago.

When my son was studying at West Point, I learned that they spent what seemed an inordinate amount of time studying the American Civil War and I asked him “Why do you do that?” He said, “Generals get their soldiers killed by fighting the current war with tactics that were appropriate for the last conflict.” I have been haunted by that statement ever since. By any objective standard, the US military has done a much better job than our medical system of adjusting their structure and practice to the new technology that is available to them.

Translation is a major emphasis – perhaps the major emphasis – in all military education. All army enlisted and officers are trained as generalists and the infantry, the organization of generalists, is the “Queen of Battle.” All of the specialty arms in the army serve the infantry as the main focus of army operations. The leaders of the army are required to attend sophisticated schools at each stage of promotion in part to prepare them to incorporate new technology..All of this has developed out of that concern that the stakes are enormous and leaders get their soldiers killed by not translating new technology into practice.

Unteroffizier Paul Scheytt could not believe his eyes. During the week leading up to this moment, July 1, 1914, he and his troops had endured artillery barrages so vicious that the British high command was quite sure that all German forces in that section of trench had been annihilated. Indeed, he was just peering over the wall of his fortification after a final savage artillery bombardment, and there before him were thousands of British soldiers, so heavily laden with equipment that they could barely walk, moving deliberately toward his position. He and his fellow soldiers thought the British were insane. He was watching the beginning of the Somme offensive.

In that single day Scheytt and his fellow German troops would shoot down 60,000 young British men. These attacking troops had come at the Germans shoulder to shoulder and were annihilated in a murderous hail of fire from machine guns, repeating rifles, mortars, and breach-loading artillery.

How could such madness happen? The English generals did not change the tactics of the assault to take into account the tremendous changes in weapon technology. They did not translate new technology into practice. The British general Haig, who ordered the attack, was bright, well-trained and conscientious, but he caused thousands of young men to die because they were fighting with tactics appropriate 100 years before that day. The technical paradigm and science had changed, but the leaders had not adjusted structure and tactics to address those realities.

The British forces attacked across a broad front as western armies had done for thousands of years. Even as the American Civil War began, the broad frontal assault was still a reasonable strategy. The musket that was far and away the main weapon in use was only accurate at 40 yards. In the first battles of the Civil War, lining up in parade formation with the regimental colors leading the way and the band playing was completely appropriate. The armies would line up across a front two or three miles wide, march to within 40 yards of each other and fire by volley. There were casualties, but losses were reasonable and the tactics and technology were fairly well matched.

By 1863, when the battle of Gettysburg was fought, the dominant infantry weapon was no longer the musket but the rifle, which could reliably kill a man at 300 yards. When General Pickett led his infamous charge, his troops were crossing nearly a mile of open field and the Union defenders were protected by a stone wall. Pickett’s division had no chance and evaporated before it got anywhere close to the Union position.

The Union generals observed this slaughter first-hand, but in May of 1864, General Grant ordered one frontal assault after another against Confederates in trenches armed with rifles. None of these assaults had the remotest chance of success, and the Union Army of the Potomac suffered 60,000 casualties in that one month – a loss equal to the entire strength of the Army of Northern Virginia.

The paradigm had changed, the solution existed, but leaders of the Civil War and even of WWI did not change the tactics of the assault. Millions died as a result.

The solution to the changes in warfare really fairly simple. The method of attack had to change radically, and once that change was made, the impregnable defense paradigm changed to one in which the irresistible assault was the reality of the day. In a moment, we went from a world where the attack seldom succeeded, to a world where the well-designed and executed attack seldom failed.

Our tactics in dealing with chronic diseases lag the available technology to a similar extent and with similar casualties. Multiple major paradigm shifts have occurred in the new science of vascular disease. Heart attack is not a plumbing problem. It is not a problem of a progressive fixed blockage that can be fixed with a stent. Stents do not prevent myocardial infarction in stable patients.

Still, our system practically functions as if it is all about the blockage. Heart attacks are prevented by stopping smoking, diet, exercise, and a coordinated, integrated pharmaceutical protocol aimed at preventing plaque rupture by aggressively treating hypertension, high cholesterol and type 2 diabetes. Today, a carefully designed program of 6 four dollar prescriptions from WalMart can make an enormous difference. Multiple clinical trials have demonstrated the effectiveness of optimal medical therapy and that is clearly our challenge – to produce best medical treatment for risk factors consistently. Our current system of care has no more chance of success than the British attack at the Somme.

We require the same drastic reorganization required of the military after WWI. We are currently organized as if hypertension, type 2 diabetes, high cholesterol, high triglycerides and gout were separate conditions. They are not.

For the majority of patients, these conditions are part of the metabolic syndrome, a single condition that is the result of a diet rich in fat, sugar and processed carbohydrates, coupled with inactivity, resulting in increased abdominal weight. The metabolic syndrome and its later stages of pre-diabetes and diabetes are the leading cause of heart attack, stroke, and other serious vascular complications.

“Changing systems of care” is not just something for the worker bees. From top to bottom our system functions as if the science of the last 20 years never happened. Even our major academic centers are still organized as if these are unrelated conditions. Most medical schools have hypertension clinics, lipid clinics, and diabetes clinics. The professionals who man these clinics organize meetings sponsored by the American Society of Hypertension, the National Lipid Association, and the American Diabetes Association respectively. Then, when these anachronistic systems fail to produce optimal medical therapy and these patients experience a plaque rupture in a coronary artery and a resultant heart attack, the patient is referred to a cardiologist. When they develop a clot in a neck artery, they see a neurologist and when they develop gout we send them to a rheumatologist.

The whole arrangement is an anachronism based on decades-old science. Until we address these fundamental realities and make the adjustments in our systems of care demanded by new technical developments, optimal medical therapy will remain an elusive dream. Until we seriously attack these structural issues, we cannot produce patient centered care.

And so, the obvious question becomes: “What changes in structure and practice would be the medical equivalent of a mechanized infantry division in the management of cardio-metabolic conditions?” The best answer today would come from a combination of “Crossing the Quality Chasm” from the Institute of Medicine (IOM) and the Advanced Medical Home from the American College of Physicians (ACP).

The IOM recommended that focused programs be developed for 15 priority conditions that included diabetes, high cholesterol, hypertension, ischemic heart disease, and stroke. Peripheral arterial disease and congestive heart failure are strongly related conditions and the whole could be managed by internal medicine and family practice providers with a special interest in these conditions. A special focused effort to address all of these conditions in a coordinated integrated way could be housed in a cardio-metabolic center of excellence within a larger practice.

That cardio-metabolic center-of-excellence team would assure that the IOM system for producing optimal medical therapy was consistently implemented along four key principles:

  • Organize evidence-based care protocols consistent with best practices
  • Organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions.
  • Develop the information infrastructure to support the provision of care and measurement of care processes and outcomes.
  • Align the incentives inherent in payment and accountability processes with the goal of quality improvement.

The ACP document on the advanced medical home describes a number of models:

“In the advanced medical home model, patients will have a personal physician working with a team of health care professionals in a practice that is organized according to the principles of the advanced medical home. For most patients, the personal physician would most appropriately be a primary care physician, but it could be a specialist or sub-specialist for patients requiring ongoing care for certain conditions, e. g. severe asthma, complex diabetes, complicated cardiovascular disease, rheumatologic disorders and malignancies…Principal care, that is, the predominant source of care for a patient based on his or her needs could be provided by a primary care physician or a medical specialist..”

This is a great new opportunity for primary care to rise out of the ashes, to produce a very high value product and to be paid fairly for it. Current systems and practice do not  produce optimal medical therapy consistently. The cardio-metabolic centers of excellence proposed here would be manned by generalists assembled in a kind of medical special operations unit, bringing together just the right mix of assets to accomplish the reliable production of optimal medical therapy for large numbers of patients. The expectation would be that the providers would train and retrain to continually improve their practices as the science and technology continue to change.

We could train generalists to become part of special teams that change with the science and technology. They would not practice primary care in the usual sense; they would not attempt to be everything to everyone. They would be the ideal principal physicians for patients with vascular risk factors and a history of vascular events. Half the population dies of these conditions and they produce nearly half the cost of care. Effectively addressing this single collection of chronic conditions offers the most impact for the cost and effort of any that I have seen proposed.

Over the last two years, our group has run a cardio-metabolic center of excellence. In providing coordinated integrated care for these conditions we have been able to show dramatic results in patients referred by the 140 clinicians in our larger practice. The entire practice has a quality culture and good outcomes. Even so, these patients have realized average reductions in the LDL of 60, A1c of 1.8, triglycerides of 200, BP of 11/9 and weight loss that averaged 9 pounds.

Good relationships and high provider satisfaction come as we attain good referral volumes from a doctor. Patient satisfaction and persistence with the program is very high. Still, most physicians in the group do not yet refer to the program.

Medical leadership has not begun to produce the level of structural change to adapt to new technology. We are in a time that will precipitate great change. Following the science, we can restructure medicine in ways that will improve lives and save enormous dollars.

William Bestermann, MD, is a Preventive Cardiologist and Medical Director for Integrative Services at the Holston Medical Group in Kingsport, TN.

Five Recommendations for an ONC Head Who Understands Health IT Innovation

Now that the legislative language of the HITECH Act — the $20 billion health IT allocation within the economic stimulus package — has been set, it’s time to identify a National Coordinator (NC) for Health IT who can capably lead that office. As many now realize, the language of the Bill can be ambiguous, requiring wise regulatory interpretation and execution to ensure that the money is spent well and that desired outcomes are achieved. Among other tasks, the NC will influence appointments to the new Health Information Technology (HIT) Policy and Standards Committees, refine the Electronic Health Record (EHR) technology certification process, and oversee how information exchange grants and provider incentive payments will be handled.

Continue reading…

Betsy McCraker misses the point, again

Not content with being the catalyst for the unleashing of a torrent of vitriol in the direction of those Milquetoast individuals who are in favor of better information systems in health care, in the mild expectation that it might improve care delivery, Betsy McCracker is back at it again. This time the NY Times prints her letter. And in it she says:

These changes will affect all of us, at the least by requiring that our treatments be recorded in a federally mandated electronic database and guiding the choices our doctors make. Yet no hearings were held, no expert witnesses called, no opinions gathered from patient advocates, doctors’ groups, the elderly or other stakeholders.

Apart from the fact that there’s no evidence of one “electronic database”, she’s missed a couple of things.

First, hearings, witnesses, etc, etc, have been held for on this topic for years, and witnesses were called in the weeks before the stimulus bill—Microsoft’s Peter Neupert among them. Peter may not be an expert in Betsy’s eyes, but I think most of us would concede that he knows something about the topic (even though much of his advice was ignored).

Secondly, Betsy McCracker seems to be missing a minor point. The Obama campaign was not shy about telling anyone who listened that they were going to spend up to $50 billion on health IT in the next five years. It was on their website, and talked about by their health care advisers non-stop, as the WaPo noticed in early December.

Why are we supposed to be surprised that they did what they said they were going to do? Isn’t that the point of democracy? So Betsy, who won the election?