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Tag: Quality

TECH/CONSUMERS/QUALITY: Information Therapy and care management

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This panel has representatives from a care management vendor (Health Dialog), a staff model integrated system (GHCPS) and a big insurer (United).

Shorter George Bennet, Health Dialog — You make $3 for every 88 cents you spend on care management when you get the doctors involved. So the answer is to get care management companies to pay doctors to deliver information therapy, and pay them based on how well their patients can answer simple questions.

Best joke (from James Hereford at Group Health Cooperative of Puget Sound) — you know you’re west of the Mississippi when the agenda has both a Holstein and a Hereford on it.

Shorter James Hereford– Group Health is a provider that takes risk (a la Kaiser), and we don’t think like other insurers (and so it has hired a recovering mathematician to improve its consumer health systems). They’ve decided that the use of the web is to integrate and spread information, based around a clinical information system (Epic) and a messaging system. They had a business case for driving integration using technology–but most organizations don’t. Their payback for their $40m investment is in five years, and some facilities have done more eVisit (touches) than actual visits for their secure messaging. Now they have one in three of their patients using it. And they saved $1.4 million in transcription costs. In addition, they believe that with each email they are replacing a phone call, which costs $16-18 or a visit which obviously costs more.

Shorter Bob Tavares, UnitedHealth Group: If you want Information Therapy and consumer portal web sites, you’d better have some goals as to what you’re trying to achieve. United’s consumers site had no goals and Bob has just been hired to figure out what they are! So create some goals about the impact web-based therapy has on for example replacing inpatient care with outpatient procedures (and BTW saving United some cash). Consumers want benefit, costs and treatment outcomes/ quality information all in one place.

QUALITY: Voluntary error reporting system eventually rolls out of Congress

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So Congress has finally passed a bill creating a voluntary medical error reporting system. Baby steps six years after To Err Is Human, but I had to turn to Michael Millenson expecting him to be overly cynical.  But do I glimpse a softening, or even some hope for real change, in his comment?  Here’s what Michael emailed to me:

Congress has taken a step with great symbolic weight but only a very modest practical effect and even more minimal funding. While this, of course, is a specialty of our national legislators, particularly in this era of tight budgets — talk big and carry a small stick — the bottom line is that the preventable deaths and injuries being suffered by tens of thousands of anonymous American hospital patients every year doesn’t push very many political buttons. If a majority of both Congress wasn’t comprised of middle-aged men and women with elderly parents, we might not have gotten any legislation at all. Still, the fact that Congress could actually pass a bill related to medical errors sends an important message to health care providers that real oversight from someone outside the industry has finally arrived.

POLICY/QUALITY: A good round up of lefty propaganda, and Berwick gets a gong

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The Christian Science Monitor has a quick diatribe on what a mess health care is, and how the HSA/CDHP movement will be a five to ten years distraction before we end up at some type of universal coverage/single payer.  The article is called Why the healthcare crisis won’t go away and is definitely worth a read as it pretty much encapsulates my views on the matter.

Meanwhile those of you who think that we need an Escape Fire will be amused to know that Don Berwick was given a Knighthood recently. Two quick explanations for you non-limeys. No he can’t call himself "Sir Donald" — you can only do that if you are a Brit (Hence "Sir" Bob Geldof isn’t).  Second, no it’s not in the least likely that the Queen picked him out of a line-up — these awards are nominated by the government, and its just an indication that the quality/pay-for-performance crowd have had quite a bit of influence across the pond.

QUALITY/POLICY: P4P get official in Businessweek, no less

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So in a remarkable bit of futurism, only 8 years after Greg Schmid invented the concept at IFTF (well, we end up calling it performance-based reimbursement, but it’s the same thing as P4P), Businessweek has noticed and Pay for Performance has gone mainstream.

I’m still looking for someone to find an earlier citation of an equivalent term or concept–I still can’t believe that we allowed a non-healthcare economist to invent the term!  And with reference to the Gianfranco post from yesterday…. Greg came into work every day for 5 years and always said to me "How come they named the football team you support after the President’s daughter?"

POLICY/QUALITY: The Nursing Shortage — It’s real

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Over at Code: the WebSocket Alwin has a really great article about the nursing shortage called A hard rain is gonna fall. I think he’s right and that after we’ve emptied every third world nation of their meagre nursing supply, we’ll realize that we have do something about it here. And in my view that means training fewer doctors and more nurses instead.

QUALITY: Want to avoid medical errors? Pick a profitable hospital

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Just found this gem.  Apparently an AHRQ study looked at the rate of medical errors in Florida hospitals and discovered that the more profitable hospitals (situated in general in areas where there were wealthier patients of course) had fewer medical errors. Intuitively this makes sense.  While any hospital can make a screw-up, such as washing surgical instruments in used elevator oil (yup really happened at Duke — read this), in general medical errors are a symptom of incomplete process engineering, and the more successful companies in any field, which also tend to be the richest, are likely to run better — or at least closer to a specified process. Of course part of that process is having the money for the systems and the people to put that process in place.

So another good reason to choose your income level, (and by extension that of your parents) carefully.

I’ll have much more tomorrow on Krugman’s entry into the single-payer fray.  But you’ll all be busy on the "Michael Jackson gets off on little boy(‘s charges)" headlines.

QUALITY/TECH: CHCF on Chronic Disease Care

I’ll review this in a little bit (getting a bit of a slow start this AM), but I wanted THCB readers to know that California Healthcare Foundation has published some more excellent studies with very practical applications. These ones focus on chronic disease. There are three. One on helping patients manage their own chronic conditions, a second on the tools available for patient self-management, and a third on the benefits and challenges of using telephone based chronic care management techniques (which is where the state of the industry is now).

Excellent practical stuff from an organization that is focused on helping make real positive change.

QUALITY/TECH: Better to have a bypass

INTERESTING TIMES for cardiologists, as new research this week in the NEJM suggests coronary bypass surgery may be a better treatment option than stents.  For those paying attention, this is not exactly news.  People have been making the argument for years.  Go read Matthew’s post "Dump the stent have a bypass", written way back in October of 2003, for a deeper look at some of the evidence supporting this theory.

YOU MAY ALSO want to take a quick look at Gregory D. Pawelski’s statement in support of embryonic stem cell research, which is a well-articulated post written from the perspective of someone who knows a bit about cancer treatment.

INTERNATIONAL/QUALITY: The Brits are in court over “how much is enough?”

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Well I was up late late last night working on some client stuff and am about to head back to that meat grinder, but for now consider this….

You may (unfortunately) remember the Terri Schiavo incident.  The Brits are playing this rather differently.  Here we’re keeping people alive who want to die (or at least we’re keeping some people who want to die alive). In the UK the issue of the NHS continuing to treat people who are going to die but who want all the stops pulled out anyway is ending up in court. Traditionally this process played out in the UK in a "stiff upper lip" way, mostly controlled by the medical profession.  Now the government is being explicit that it feels some medical care is a waste of resources. Pretty interesting stuff, because of course they are right, and the same thing is going in here but no one has the cojones to point it out.  But with the baby boomers about to hit Medicare and the Federal budget in the pocketbook, and way too much excessive care of the nearly dead going on in America’s ICUs,  the day when this discussion starts here will come.

PHARMA/QUALITY: Can Cancer Care Get Better? by Greg Pawelski

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AP Biotechnology Writer, Paul Elias,  wrote an article this week that described how while the cost of cancer drugs have skyrocketed, the benefits are less apparent. It’s been more than 30 years since we declared a war on cancer and although there have been some real triumphs, and some great advances, the overall picture is not good. Tomorrow one of my closest friends is going into the local oncology center for the removal of what we all hope are some benign breast lumps. This post is dedicated to her, and to all those with cancer or at risk for cancer. Part of the issue is surely environmental, and we have much more to learn about what causes cancer and whether the toxins that we put into the planet are coming back to attack us.  Part of the issue, though, is how we approach cancer care.  THCB contributor Greg Pawelski has written before about the need for more chemosensitivity testing, and now writes on how we can use what we know to more effectively care for patients.


We have produced an entire generation of investigators in clinical oncology who believe that the only valid form of clinical research is to perform well-designed, prospective, randomized trials in which patients are randomized to receive one empiric drug combination versus another empiric drug combination. The problem is not with using the prospective, randomized trial as a research instrument. The problem comes from applying this time and resource-consuming instrument to address hypotheses of trivial importance (i.e. do most cancers prefer Pepsi or Coke?).

There are 60-80 different therapeutic drug regimens out there, any one or in combination can help cancer patients. The system is overloaded with drugs and underloaded with wisdom and expertise for using them. Government and academic clinical investigators have failed to support the individualization of chemotherapy through laboratory testing, in favor of attempts to identify "one size fits all treatments" through trial and error testing which has consumed tens of thousands of human lives. This entire effort has been a colossal failure and a colossal waste of human and financial resources.

One of the main problems in providing effective chemotherapy is the situation that every patient is unique. Tumors grow and spread in different ways and their response to treatment depends on these characteristics. The amount of chemotherapy that each patient can tolerate varies considerably from patient to patient. Therapeutic protocols currently in use are limited in their effectiveness because they are based on the results of clinical trials conducted on a general patient population, yet no two patients are alike. Chemosensitivity testing can help to improve the efficacy of cancer therapies on an individual patient basis.

Without the information provided by chemosensitivity testing, oncologists have the freedom to choose between multiple different drug regimens, all of which have approximately the same probability of working. Some of these regimens are highly profitable to oncologists. Other regimens are much less profitable. Pre-screen testing takes away a lot of this freedom to choose and narrows the selection to those drugs that have the highest probability to be successful but may have lower profitability for the oncologist. This cuts into the oncologist’s bottom line, though it benefits the patient.

The hallmark of the disease is heterogeneity, yet the powers that be insist on trying to homogenize it, rather than tailoring treatment to the individual nature of the disease. If we devoted 10% of the "one-size-fits-all" resources to developing and testing methods to individualize therapy, we’d have actually made some progress at lowering the costs of cancer drugs.

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