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Tag: Quality

Value-Based Reform

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By JACK COCHRAN, MD and CHARLES KENNEY

Cochran THCBThe U.S. Department of Health and Human Services’ recent announcement to move the Medicare program toward value-based payments is among the most promising recent developments in health care.

While changing the way we pay for care will not be easy, we believe that shifting away from fee-for-service to value-based payments could be a catalyst to a better, more affordable health care system in our country.

Three Benefits of Paying for Quality
There are numerous potential benefits to paying for quality rather than quantity, including the three we want to focus on today.

  1. We believe this payment shift has the potential to accelerate progress toward achieving the Triple Aim – defined as better individual care, better population care, and lower cost.
  2. We believe the payment shift by Medicare will accelerate the transition to value-based payments among commercial insurers – a major benefit to employers in terms of improved health for employees and greater affordability.
  3. We believe value-based payments have the potential to help slow – and possibly reverse – the epidemic of physician burnout in the United States, particularly among primary care doctors.Continue reading…

Using a Mobile App for Monitoring Post-Operative Quality of Recovery

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By JAAN SIDOROV, MD

flying cadeuciiWhile your correspondent is tantalized by the prospect of healthcare consumers using mHealth apps to lower costs, increase quality and improve care, he wanted to better understand their real-world value propositions.

Are app-empowered patients less likely to use the emergency room?

Do they have a higher survival rate?

Do they have higher levels of satisfaction?

In other words, where’s the beef?

That’s when this paper caught my search engine eye. It’s a report on using an app to monitor post-operative patients at home.Continue reading…

Germs. The Pseudoscience of Quality Improvement

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By Karen Sibert, MD

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No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

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A Doctor is a Doctor is a Doctor, Right?

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HANS DUVEFELT, MD

flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

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ACOs Are Doomed / No They’re Not

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By THCBist

A number of pundits are citing the systemic failure of ACOs, after additional Pioneer ACOs announced withdrawal from the program – Where do you weigh in on the prognosis for Medicare and Commercial ACOs over the next several years?”

Peter R. Kongstvedt

KongstvedtWhoever thought that by themselves, ACOs would successfully address the problem(s) of [cost] [care coordination] [outcomes] [scurvy] [Sonny Crockett’s mullet in Miami Vice Season 4]? The entire history of managed health care is a long parade of innovations that were going to be “the answer” to at least the first four choices above (Vitamin C can cure #5 but sadly there is no cure for #6). Highly praised by pundits who jump in front of the parade and declare themselves to be leaders, each ends up having a place, but only a place, in addressing our problematic health system.

The reasons that each new innovative “fix” end up helping a little but not occupying the center vary, but the one thing they all have in common is that the new thing must still compete with the old thing, and the old thing is there because we want it there, or at least some of us do. The old thing in the case of ACOs is the existing payment system in Medicare and by extension, our healthcare system overall because for all the organizational requirements, ACOs are a payment methodology.

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Health Value: IT and the Rise of Consumer Centricity

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CYNDY NAYER

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Accountable care demands that the system sync with the preferences and choices of the consumer purchasing the services.  In order to get to real health value, consumer-patients must make the health care decisions that improve personal health and do not derail personal bank accounts.  It was hard to piece these together for the last 15 years.  Now, with high deductible plans, more transparency for costs, and on-time digital connectivity, there is less difficulty.

Information technology can deliver the needed information to the patient and the physician to improve not only the likelihood of improved care but also the time-to-achieve the outcomes.  Most patients want and need to be involved in their care.  There is evidence that giving patients access to their information results in higher levels of engagement and adherence to recommendations.  In fact, the latest evidence shows that patients have been signing up for access to their health system portals at a rate of 1% per month for over 30 months.

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Changing My Mind on SES Risk Adjustment

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ASHISH JHA, MD

Ashish JhaI’m sorry I haven’t had a chance to blog in a while – I took a new job as the Director of the Harvard Global Health Institute and it has completely consumed my life.  I’ve decided it’s time to stop whining and start writing again, and I’m leading off with a piece about adjusting for socioeconomic status. It’s pretty controversial – and a topic where I have changed my mind.  I used to be against it – but having spent some more time thinking about it, it’s the right thing to do under specific circumstances.  This blog is about how I came to change my mind – and the data that got me there.

Changing my mind on SES Risk Adjustment

We recently had a readmission – a straightforward case, really.  Mr. Jones, a 64 year-old homeless veteran, intermittently took his diabetes medications and would often run out.  He had recently been discharged from our hospital (a VA hospital) after admission for hyperglycemia.  The discharging team had been meticulous in their care.  At the time of discharge, they had simplified his medication regimen, called him at his shelter to check in a few days later, and set up a primary care appointment.  They had done basically everything, short of finding Mr. Jones an apartment.

Ten days later, Mr. Jones was back — readmitted with a blood glucose of 600, severely dehydrated and in kidney failure.  His medications had been stolen at the shelter, he reported, and he’d never made it to his primary care appointment.  And then it was too late, and he was back in the hospital.

The following afternoon, I spoke with one of the best statisticians at Harvard, Alan Zaslavsky, about the case.  This is why we need to adjust quality measures for socioeconomic status (SES), he said.  I’m worried, I said. Hospitals shouldn’t get credit for providing bad care to poor patients.  Mr. Jones had a real readmission – and the hospital should own up to it.  Adjusting for SES, I worried, might create a lower standard of care for poor patients and thus, create the “soft bigotry of low expectations” that perpetuates disparities.  But Alan made me wonder: would it really?

To adjust or not to adjust?

Because of Alan’s prompting, I re-examined my assumptions about adjustment for SES. As he walked me through the data, I concluded that the issue of adjustment was far more nuanced than I had appreciated.

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It’s a Trade-Off, Stupid.

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SAURABH JHA, MD

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An advantage of being a foreigner, or a recent immigrant to be precise, is that it allows one to view events with a certain detachment. To analyze without the burden of love, hate or indifference for the Kennedys, the Clintons or the Bushes. To observe with both eyes open, rather than one eye looking at the events and the other looking at a utopian destination.

The most striking thing I’ve observed in the healthcare debate in the US is the absence of an honest discussion of trade-offs.

I’ve found that “trade-off” carries a sinister connotation in American healthcare parlance. Its mere utterance is a defeatist’s surrender. If optimism is the iron core of the United States, acknowledging trade-offs is her kryptonite.

I was raised in Britain. I learnt to guard optimism with pursed lips. You never knew when it would rain. I also learnt in Britain’s NHS where healthcare resources really are finite, there is a trade-off between coverage and access.

In the discussions preceding the implementation of the Affordable Care Act (ACA) two disparate truths were conjoined by a single solution. The unsustainable trajectory of healthcare spending. And the large number of uninsured population. It was scarcely acknowledged that solution of these problems are inherently oppositional.

This has led to the search for utopian payment models. Fee for service incentivizes physicians towards generously reimbursable services of marginal benefits. Capitated systems dissuade physicians from taking sicker patients.

How about we pay for outcome, value and quality?  Sounds simple enough.

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It is Time for Clinicians to Engage: Let’s Criticize Less and Dare Greatly More

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By JOHN HAUGHOM, MD

John Haughom MD whiteWhen I write or speak about healthcare transformation, I am often asked why I do not criticize more. Criticize health system leadership. Criticize governmental policies. Criticize burdensome regulations. It’s a long list. Why avoid criticism? The answer is simple. Discerning emerging solutions is much more productive and fun.

We are living during a very interesting period in the history of health care. No doubt, it is a time of great transition. We are passing from one time to another. Transition periods are important, yet they are hard to define because it’s difficult to determine exactly when they start and when they end. To understand the transition healthcare is now experiencing, we must do our best to understand what is on either side of it.

The traditional approach to delivering care has served us well and accomplished great things over the past century. Yet, it is also being overwhelmed by complexity and producing inconsistent quality, unacceptable levels of harm, too much waste and spiraling costs.

The traditional method of delivering care is struggling and another is emerging to take its place. Because the traditional approach has served us well and accomplished great things, we want to believe that the present state will continue forever. Because conditions have changed, this will not happen. We are in need of a new approach. An approach that carries the best of the past forward, yet also addresses present day challenges. It just might be that on the other side of this current transition is potentially a time unmatched by any other in the history of healthcare. Thanks to visionary clinical leaders at institutions across the country, there is growing evidence this is not only possible; it is likely.

Who does the future belong to? If we look closely at other transition periods in history, two groups of people are apparent. The first are what we recognize as critics. They are people whose response to the need for change is criticism. Critics always exist, but in a time of transition they tend to multiply. What do they criticize? They criticize the new, they criticize the change, they criticize the change for being unnecessary or too fast, or they criticize the change for being too slow. They criticize anything and everything. Critics are abundant. The question we should consider is, “Will criticism solve problems?” Typically, it does not.  While constructive criticism has its place, it alone is not likely to accomplish much especially when the world is yearning for innovative solutions.

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Who Is the Better Radiologist?

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By SAURABH JHA, MD

flying cadeuciiThere’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

Continue reading…

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