Tag: Kent Bottles

Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?

Jun 28, 2011• 35

By KENT BOTTLES, MD

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act.Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.”

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.”

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care – particularly fictitious care – we’ve got a problem. Is this a new quality standard we can expect from our new government health care initiative? Just like scam-artists that phish for unsuspecting people’s financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud – plain and simple.”

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

Physician Executives Should Not Ignore How Smartphones Will Transform Healthcare

Jan 31, 2011• 15

By KENT BOTTLES

Physician executives who ignore smartphones and their healthcare applications will miss the most important disruptive technology trend in the next five years. Physician executives who understand how smartphones will transform the industry for providers, payers, patients, and employers will thrive in their careers.

Rajeev Kapoor, a former executive at Verizon, describes the smartphone-enabled transformation: “The paradigm of healthcare has changed. You used to bring the patient to the doctor. Now you take the doctor, hospital, and entire healthcare ecosystem to the patient.” (http://ow.ly/3GIir) Susannah Fox of the Pew Research Center’s Internet and American Life Project offers a specific example when she talks about the celiac disease patient who uses her smartphone to evaluate food products in the grocery store.

“You cannot call your gastroenterologist every time you buy a new product.” (http://e-patients.net/index.php?s=fox) David Jacobson of Wellpoint notes that “The technology of telehealth is well ahead of the socialization of the telehealth idea and we are at a tipping point for utilization to begin taking off.” (http://ow.ly/3GIir)

The Global mHealth Developer Survey found that today 78% of respondents said that smartphones offer “the best business opportunities for mobile healthcare” in 2011; by 2015, 82% said smartphones would dominate the industry. Cell phones, tablets, and PDAs trailed smartphones in popularity according to the survey. (http://ow.ly/1aVf9V)

ACOs and Community Hubs of Wellness & Health

Jan 23, 2011• 18

By KENT BOTTLES, MD

Hospitals are going to change. What worked in the past will not work in the future. The passage of the federal health care reform law and the inevitable transition from fee for service to global payments is changing the rules of the hospital game. Hospitals will have to make do with less financial support from both government and private payers and at the same time deliver higher quality health care with measurably better outcomes. Hospitals will take care of fewer and fewer patients as care continues to migrate to the outpatient setting, the home, and wherever citizens live carrying their smart phones. The development of Accountable Care Organizations (ACOs) to receive and distribute these global payments will affect hospitals whether they decide to take a leadership role or a wait and see attitude. There will be winners and losers among hospitals; there will be fewer hospitals in America in ten years than there are today in 2011.

Hospitals that survive this transformation of the health care delivery and payment system will become the community hub of wellness and health (CHWH) that citizens turn to in a time of rapid and chaotic change. Becoming a CHWH will require hospitals to expand their services and expertise well beyond the traditional role of an acute care facility. It will also require hospitals to embrace social media and disruptive digital tools that are now available to help care for a defined population living in the community. Hospitals will have to forge a new culture or their ACOs will fail, no matter how sophisticated and expensive their legal structures and physician integration plans become.

Hospital leadership seems ill prepared for this transformation in mission. Robert Naldi, the CFO of Maimonides Hospital in Borough Park, Brooklyn, is not alone when he says, “I don’t spend a lot of time thinking about global issues. When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning…. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.” (http://ow.ly/3Dlxp)

Hospital Culture and Surviving the New Landscape

Jan 11, 2011• 14

By KENT BOTTLES, MD

A recent flight on Southwest reminded me of the importance of culture in navigating change in a rapidly evolving environment like we have in health care in the United States today. It is all too easy to focus on all the technical issues hospitals face in setting up Accountable Care Organizations to handle the inevitable global payments that will replace the current fee for service system. This blog is a plea for hospitals and doctors and consultants to pay attention to both the technical and the cultural or adaptive challenges we face in transforming a $2.5 trillion American industry.

Recent articles on companies outside of health care have highlighted how important culture has been to the success or failure of Southwest Airlines, QVC, and Zagat to respond to changing business conditions. Southwest’s COO states “our culture is our biggest competitive strength,” and the flight attendant and pilots’ union worry about how the recent purchase of AirTran will affect their unique culture. I have seen Southwest pilots help clean up the cabin, and the flight attendant on my recent trip told me she was giving up her day off because the company needed her help. QVC is trying to use the same methods and culture that made selling on TV popular with Internet customers. And Zagat, which had cultural troubles moving from book format to online, is now hoping that smart phone applications will reinvigorate their business model.

Harvard’s Ron Heifetz differentiates between technical and adaptive work and I have found this concept useful in working with health systems responding to payment reform. Everyone involved in hospital physician integration efforts will need to undergo a cultural (adaptive) shift because the healthcare reform law and the transition from fee for service to global payments mean the old ways of doing things are not sustainable.

What Would A Truly Patient-Centered ACO Look Like?

Jan 3, 2011• 14

By KENT BOTTLES, MD

Health care leaders are busy talking to attorneys and consultants about how to set up Accountable Care Organizations (ACOs). A recent Advisory Board survey found that 73 per cent of hospital finance executives said that creating such an organization was a top priority for their health system.

Last year my most popular keynote topic was patient-centered medical home creation; this year everyone wants a presentation on ACOs.

However not everyone has jumped on the ACO bandwagon. Bruce Bagley, MD of the American Academy of Family Practice was recently quoted as saying, “There are probably no experts about ACOs. It’s a developing concept.” And Jeff Goldsmith, PhD, of the University of Virginia stated at the same conference: “I think this is a stupid idea. Managed care without the risk – that’s like gin and tonic without the gin. How do you end up making choices if you’re not forced to make them?”

I started thinking about what an ACO would look like if it was truly patient-centered. What if we designed an ACO that gave patients what they say they really want?

Don Berwick wrote an article in Health Affairs in 2009 that examined what patient-centered should mean, and since he became the head of Medicare in 2010 it might make sense to start there. After all, Medicare is pushing the ACO concept by creating pilot projects and encouraging the shift from fee for service payments to global payments for medical care reimbursement.

The Difficult Science, Part II

Dec 28, 2010• 19

By KENT BOTTLES, MD

“Despite their great explanatory powers these laws [such as gravity] do not describe reality. Instead, fundamental laws describe highly idealized objects in models.”

— Nancy Cartwright, “Do the Laws of Physics State the Facts?”

In Part I the limitations of science in helping us make wise choices and decisions about our health were examined.

Because of an inherent difficulty in establishing causation, absolute certainty is unattainable even in science. Medical knowledge follows Karl Popper’s theory of science because the right answer, whether about what causes ulcers or if you should take hormone replacement therapy, keeps changing with the publication of new studies. And most depressingly of all, a respected expert on evidence-based medicine concludes, “The majority of published studies are likely to be wrong.”

Part I ended with some suggestions that seemed to imply that savvy patients should enroll in a graduate level statistics class and understand the subtleties of observational studies, meta analysis, and randomized controlled clinical trials. Being an informed health care consumer is evidently difficult indeed.

Part II explores how we all have to change if we are to live wisely in a time of rapid transformation of the American healthcare system that everyone agrees needs to decrease per-capita cost and increase quality.

PATIENTS

When I talk to physicians about pay for performance programs, I am always asked why should doctors be responsible for patient behavior that they cannot control. Even if we were able to have health care access for all and eliminate every error in medicine, we would only account for 10% of whether an individual stays healthy. Environment and genetics account for about 35%, but the remaining 55% of whether one stays well depends on behavior (exercise, smoking, diet) and social support systems (families, communities, places of worship).

The Difficult Science

Dec 25, 2010• 21

By KENT BOTTLES, MD

“The mind leans over backward to transform a mad world into a sensible one, and the process is so natural and easy we hardly notice that it is taking place.” Jeremy Campbell

On the same day in November, headlines from the Wall Street Journal and the New York Times reported on the same story about a federal panel’s recommendations on consumer intake of vitamin D.

“Triple That Vitamin D Intake, Panel Prescribes” read the WSJ story;

“Extra Vitamin D and Calcium Aren’t Necessary, Report Says” stated the New York Times. (http://ow.ly/3tJMe) Since I had recently started taking vitamin D daily, I was interested in what the experts in Washington, DC were recommending.

How should you decide what advice to follow about the relationship between your diet, lifestyle, medications, health, and wellness?

Is this just another example of how the media does a terrible job? Many of us resonate with the view of media watchdog Steven Brill who said, “When it comes to arrogance, power, and lack of accountability, journalists are probably the only people on the planet who make lawyers look good.” (http://ow.ly/3tKdM)

The media does play a role here and needs to improve, but it turns out that it is really complicated to figure out what the “truth” is about diet, exercise, medicines, and your individual well being. Everybody (journalists, government panel members, scientists, patients, physicians, and nurse practitioners) needs to change.

Will Avatars, Robots, and Video Games Replace Doctors?

Dec 16, 2010• 10

By KENT BOTTLES, MD

I have never met Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health, Susannah Fox of Pew Research Center’s Internet and American Life Project, or Professor Andy Clark of Edinburgh University face to face in the real world. And yet they have all profoundly changed the way I think about health care’s most vexing problem: how are we going to take care of all these Baby Boomers who are starting to retire and get sick?

Kvedar nicely summarizes this supply and demand problem on one slide in a talk I watched on YouTube; he notes that there are currently 24 million Americans with diabetes, and the rate is increasing 8% every year. One in three Americans over 20 years old have hypertension, and Kvedar wonders where we are going to get all the doctors to care for these patients. His answer is we need to form trusting relationships with technology in a process he terms Emotional Automation. (http://e-patients.net/index.php?s=fox)

I had never heard of Kvedar or the Center for Connected Health until I saw a Fox twitter link to her blog post about robots, enchanted objects, and networks. (http://e-patients.net/index.php?s=fox) Fox and I follow each other on Twitter, so I read her blog, which included the embedded YouTube video of Kvedar speaking about Emotional Automation. In a way Fox is also responsible for me knowing about Professor Clark’s views on “embodied cognition” and “the extended mind.” One Sunday Fox noted in a tweet that my habit of aggregating the health care news every morning at 5:30 AM was helpful to her and the rest of my twitter tribe. That one pat on the back encouraged me months later to scour the New York Times blogs where I found Professor Clark’s Opinionator blog titled “Out of Our Brains.”

Slow Medicine

Dec 5, 2010• 37

By KENT BOTTLES, MD

I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.

Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care.

McCullough describes slow medicine as “care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.” Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine.

UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, “If you come into this hospital, we’re not going to let you die.” This is a statement that puzzles me as an old time anatomic pathologist.