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Tag: Transparency

Why Transparency Doesn’t Work.

The Cleveland Clinic is by far the best provider of cardiac care in the nation. If you have cancer there is no better place to be than Texas. Johns Hopkins is the greatest hospital in the America.

Why? Because US News and World Report suggests as much in its hospital rankings.

But which doctors at the Cleveland Clinic have the highest success rates in aortic valve repair surgeries? What are the standardized mortality rates due to cancer at University of Texas MD Anderson Cancer Center? Why exactly is Johns Hopkins the best?

We don’t have answers to these types of questions because in the United States, unlike in the United Kingdom, data is not readily available to healthcare consumers.

The truth is, the rankings with which most patients are familiar provide users with little. Instead, hospitals are evaluated largely by “reputation” while details that would actually be useful to patients seeking to maximize their healthcare experiences are omitted.

Of course, the lack of data available about US healthcare is not US News and World Report’s fault – it is indicative of a much larger issue. Lacking a centralized healthcare system, patients, news sources, and policy makers are left without the information necessary for proper decision-making.

While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting. If you’re a patient in the United Kingdom, you can look up everything from waiting times for both diagnostic procedures and referral-to-treatment all the way to mortality and outcome data by individual physician.

This is juxtaposed to the US healthcare system, where the best sources of data rely on voluntary reporting of information from one private entity to another.

Besides being riddled with issues, including a lack of standardization and oversight, the availability of data to patients becomes limited, manifesting itself in profit-driven endeavors like US News and World Report or initiatives like The Leap Frog Group that are far less well-known and contain too few indicators to be of real use.

The availability of data in the United Kingdom pays dividends. For example, greater understanding of performance has allowed policy makers to consolidate care centers that perform well and close those that hemorrhage money, cutting costs while improving outcomes.  Even at the individual hospital level, the availability of patient data keeps groups on their toes.

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Some Predictions on How Medicare Will Release Physician Payment Data

The federal government’s announcement last week that it would begin releasing data on physician payments in the Medicare program seems to have ticked off both supporters and opponents of broader transparency in medicine.

For their part, doctor groups are worried that the information to be released by the Centers for Medicare and Medicaid Services will lack context the public needs to understand it.

“The unfettered release of raw data will result in inaccurate and misleading information,” AMA President Ardis Dee Hoven, MD, said in a statement to MedPage Today. “Because of this, the AMA strongly urges HHS to ensure that physician payment information is released only for efforts aimed at improving the quality of healthcare services and with appropriate safeguards.”

On the other hand, healthcare hacker Fred Trotter has raised concerns about CMS’ plan to evaluate requests for the data on a case-by-case basis. That isn’t much of a policy at all, he wrote, giving federal officials too much discretion about what to release.

So, how is this all going to shake out?

Three recent examples offer some clues.Continue reading…

The People’s Hospital

I was just recently in Guiyang, the capital of the Guizhou province in China and had a chance to visit the Huaxi District People’s Hospital (HDPH), one of the largest “secondary” hospitals in the province.

Like the rest of China, it has been gripped by the construction boom, recently opening a new surgery center and revamped medical facilities.  They had a terrific EHR from a local vendor — probably more sophisticated than a majority of U.S. hospitals.

Despite being in one of the poorest regions of China, the hospital has more money than it knows what to do with (so says its leadership) and is planning further expansion. The source of its wealth?  A growing middle class that wants more healthcare services and has the ability to pay for it.

Background on hospitals in China

There are approximately 2853 counties in China across 33 provinces.  Each county has a county hospital, a government owned facility that serves the people of that community.  When the patient is too complicated to be managed there, he or she is transferred usually to a secondary hospital.  Patients who need an even higher level of care are sent to the regional tertiary care hospital.  The gatekeeping system is weak – one need not start at the county hospital – and in fact, a majority of the inpatients at GPH came there directly.

A few years ago, China launched a major health reform with the goal of getting to universal coverage.  They got close and nearly every citizen now has health insurance that covers at least part of the costs of their care.   The insurance has substantial co-pays and doesn’t cover more expensive drugs and tests.  What does this mean for a hospital like HDPH?  About 40% of their revenues came from insurance.

And, despite being a government hospital, only about 5% of revenues came from the government.  The rest?  From the patients themselves.  This revenue mix is supposedly pretty typical of county and secondary hospitals across the nation. Out of pocket spending remains substantial, despite universal health insurance.  In fact, in absolute dollar terms, patients are paying about as much out of pocket now as they were before social insurance kicked in.

Huaxi District People’s Hospital

Outpatient clinics, where a typical appointment might last 2-3 minutes, are by far the biggest source of admissions to the hospital.  But the hospital also has an ER.  Actually, two: a Medicine ER and a Surgery ER.  The patient gets to choose.  Unsure about which you need? There is an “Enquiry” nurse who can help.  I peppered the one on duty with various clinical scenarios and was impressed with the speed and confidence with which she made decisions.

The flow is simple: you choose your ER, you register, pay the fee in cash, and go inside to wait.

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Information Asymmetry – The Politics of Health IT Policy

Let’s recognize Healthcare.gov as the dawn of mass patient engagement – and applaud it. Before this website, patients were along for the ride. Employers choose most of the insurance benefits, hospital web portals are an afterthought, and getting anything done with an insurance company, for both doctors and patients, means a phone call and paper. Can you imagine going online to find out the actual cost and buy anything? All that changed with Healthcare.gov.

Information is valuable and not evenly distributed. The haves are immensely valuable corporations. The have nots are patients and doctors. Welcome to the world of health IT politics where the rich get richer ($20 Billion of “incentives” have caused massive health IT consolidation and a hidden health surveillance state) and the poor get frustrated (talk to an independent physician about their EHR or to a patient trying to access her own health records).

Information asymmetry drives $1 Trillion waste of our $2.7 Trillion health care cost. That waste is about $3,000 per year per citizen.

The politics of health IT policy are not left vs. right but institution vs. individual. Politicians and regulators alike are now scrambling to understand the role of health IT policy in that $3,000 annual waste per citizen.

The asymmetry that drives health IT policy is easy to understand when you consider that health IT is sold to corporations. As physicians and patients, we do not prescribe or buy information technology and we are paying the price through a total lack of price and quality transparency.

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A Time of Change at the American Board of Internal Medicine

Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…

How UCSF Is Solving the Quality, Cost and Value Equation

I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.

“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.

It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.

That run has ended.

Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).

These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.

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Using Price Transparency Data Within the Hospital

Last week, CMS unilaterally released chargemaster data from 300 hospitals around the country. As David Dranove summed up well in his recent piece, this is an old hat. Yes, there are big variations in hospitals’ chargemasters. And yes, there is a lot of buzz around consumer price shopping.

A Kayak for hospitals is all well and good, but hospitals are cash-strapped as it is and there is only so much money to be saved by driving down the costs the hospital charges the health care plan unless the waste within the hospital is addressed. I would like to highlight perhaps one of the most exciting things going on under the radar in US healthcare today: using price transparency data within the hospital.

Hospitals are now reimbursed a capitated amount according to each patient’s diagnostic-related group. Capitated payment means, essentially, that the hospital receives a set amount of dollars for each patient that walks through its doors with a given diagnosis — say, $X for a patient with pneumonia or $Y for a patient with MI. Regardless of how many drugs, tests, or scans the hospital uses for the patient, it will still get the same compensation from the insurance company.

Yet, the physician up until now still acts as a kid in a candy store, running up a bill without awareness of cost or value. This is largely because the doctor is ordering from a menu without prices. I have talked to many physicians, in both out-patient and in-patient settings across seven health care systems around the country — they want a menu with prices.

I have seen firsthand the motivation for this, as pay-for-performance model is beginning to take over with my own practice. Gone are the days where doctors’ salaries are unhitched to the cost-effectiveness of care. Everyone is now in the same boat.As a neurologist, I want to share a few examples regarding stroke care that illustrate the potential savings available from educating physicians regarding cost, and also some pitfalls to avoid that could compromise patient care.

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The Rest of the Story About Hospital Pricing

The recent Medicare report on variation in hospital “prices” is not exactly news. In fact, I wonder why anyone (including the NY Times and NPR) covered it, let alone make it a lead story.

As you probably know, Medicare reported that hospital charges for specific treatments, such as joint replacement surgery, greatly vary from one hospital to another. (This includes charges for all services during the hospitalization, including room charges, drugs, tests, therapy visits, etc.) Everyone in the healthcare business knows that charges do not equal the actual prices paid to hospitals, no more than automobile sticker prices equal the prices that car buyers actually pay. Except that for the past thirty years, the gap for hospitals greatly exceeds (in percentage terms) the gap for cars. This is not just a nonstory, it is an old nonstory.

So reporters tried to give it a new spin. One angle concerns the uninsured, who may have to pay full charges. I will write about this in a future blog. Another angle is that by publishing these charges, Medicare will encourage patients to shop around. That is the subject of this blog.

I suppose it is okay to tell patients that the amount they might have to pay out of their own pockets may vary from one hospital to the next. But the published charge data is useless for computing out of pocket payments; in fact, it may be worse than useless. As even the NY Times noted, insured patients make copayments based on prices that their insurers negotiate with hospitals. These prices are essentially uncorrelated with charges. So a patient who visits a hospital with low charges may well make higher out-of-pocket payments than a patient who visits a high charge hospital. It is a crap shoot.

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The Story Behind the CommonWell Story

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

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

That was the last straw.

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

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The Smarter Healthcare Consumer Myth

If consumers could review and shop for health care coverage as easily as they do television sets, costs would decline and we wouldn’t have as large a health care crisis. At least that’s what some folks would lead us to believe. But the picture isn’t that clear.

A recent article in The Wall Street Journal reports how companies are using private health insurance exchanges to lower costs and give employees more flexibility. The exchanges are similar in nature to those mandated by the Patient Protection and Affordable Care Act (a.k.a. Obamacare)—the difference being a private company is overseeing the exchange and not the federal government or states. Employees are able to log on to a site, review coverage plans with different benefits and a range of deductibles, and choose what works best for their budget.

A consultant running one such exchange was enthusiastic about its progress thus far. “When people are spending their own money, they tend to be more consumeristic,” Ken Sperling, national health exchange strategy leader for Aon Hewitt, a unit of AON Plc, told the Journal. (Aon itself, as well as Sears Holdings Inc. and Darden Restaurants are using a new Aon run exchange.) Benefits consultants Mercer (part of Marsh & McLennan Cos.) and Buck (part of Xerox) are rolling out similar private exchanges.

There’s no doubt that consumers are more astute, on average, regarding price for benefit when directly paying for goods and services.

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