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TECH: Why physicians don’t want email from patients

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Headline: Patient-Doctor E-mail Could Cut Income for Physician Practices. Kaiser Permanente Northwest’s Clinical Systems Planning and Consulting group did a study on its patient-physician email use in its NorthWest region and found that it worked as it was supposed to. Visits down 7-10%. Phone calls down 15%.

This is of course great news. Productivity goes up, patients are happier and their care is probably better. Of course in the bizzaro world of health care that we live in, this would translate into a 7–10% decline in primary care physicians’ incomes. Which is why RelayHealth et al raise suspicion of their potential customers, and why we have to get them off the fee-for-service treadmill ASAP.

POLICY/HEALTH PLAN: Karen Ignagni lie of the day

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AHIP’s response to Sicko. Lined up in “cut to” style with answers but no questions so that it can be dropped into local news (check out the weird “B-roll” at the end). And again some of what she says is reasonable, if not a real reflection of what most of her members have been doing for the last 7 years.

But always the lie, always. She just can’t help it!  Go to minute 1.00 of the video. Note what she says about Canada. And then take a look at the data.

POLICY: Jonathan Weiner, pulling no punches on what’s wrong

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Jonathan Weiner, Professor of Health Policy and Management at Johns Hopkins, tells it like it is in a great interview at Managed Care magazine. It’s so good I’ve extracted several real zingers. I particularly love the last one about “getting the government out of the way of the market.” Here’s a selection:

“Other developed countries have come to two realizations that we have not come to. One is that it is immoral — or at best, amoral — not to provide health care to everybody if we believe that basic health care is a sign of a developed country.”

“The second realization is that other countries acknowledge that the collective — social insurance programs like the sickness funds of Germany, government agencies, or third parties that look very much like our insurance or managed care companies — cannot provide everything for everybody.”

“When managed care plans, working mainly as agents for employers and government, tried to make some necessary changes and do the right thing, nobody would let them. We shot the messenger. We’re lousy at doing what’s necessary in our health care system. Tightly controlled managed care as envisioned in the ’90’s in the Clinton reform plan is not managed care today. I’m a big supporter of good forward-thinking managed care on the part of executives and clinicians, and I definitely support the appropriate role of the market and consumerism. But we can’t lose sight of population-based care and public policy issues that don’t come naturally to managed care organizations facing pressure every quarter to make a profit and keep investors happy.”

“Within a generation or two, we’ll see the positive side of health information technology. Health care will actually get more humane, with more human interaction and more communication, because the technical side of what doctors do now will be handled by the electronic box. Things like figuring out what tests should be ordered, what drugs should be used, looking at an EKG and comparing it to the evidence will all be done better by electronic systems, using algorithms developed by doctors at places like Cleveland Clinic and Johns Hopkins. Doctors will need to be communicators, facilitators, coordinators, and coaches. I believe that model will favor women doctors, because they happen to be better at those skills.”

“Every advanced HIT system I’ve studied — the British, Hong Kong, Kaiser Permanente, and Geisinger Health System in the U.S. — has a centralized rational entity that looks at the big picture and sees itself as being in this for the long haul.”

“Our health care system is the most expensive in the world by a factor of two, and the most inefficient probably by a factor of three. Yes, we pay our doctors and administrators more and patients who get care get a lot more, but a lot of the cost difference is due to waste. We need clinical research of the type funded by NIH, and we need more operational population-based research. The Agency for Health Care Research and Quality is terribly underfunded now, and once genomics come more fully on line, research into cost effectiveness will become even more important”

“I serve on the Medicare Coverage Advisory Committee, an academic group, and I can tell you that Medicare has nowhere close to the authority it needs. There’s a lot of good people at CMS trying to do a good job, but their hands are tied by legislation. In most cases, they are not allowed to look at cost-benefit issues.”

“Q: Who’s persuading Congress to maintain the status quo? WEINER: Device manufacturers, pharmaceutical companies, everybody and their mother. God bless Big Pharma for keeping the new technology coming out. We may all need it one day, but it doesn’t all work equally well, and it certainly isn’t all cost effective. We cannot as a society pay for everything for everybody. That is absolutely impossible and totally unethical as long as we have 18,000 people a year dying — the equivalent of fifty 747’s going down — because they lack health insurance. My tone and tune will change once we have basic health care for all. We are a rich country and we absolutely can afford it, as long as we operate within a budget.”

“When a young doctor or medical school dean tells me that in this country the market does what the market should do, and government should keep out of it, I tell them that’s fine, as long as they’re willing to return the million and a half dollars in federal and state subsidies for each doctor trained. A plastic surgeon practicing in the fanciest suburb in any city gets more of a subsidy than the family doctor practicing in an inner city or rural area, and that’s not right. Moreover, the plastic surgeon can make a half million dollars a year, while the inner city doctor is making a hundred thousand.”

POLICY: Beating up on the loony right once Moore

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So there’s a movie called Sicko out and it has the right really riled up. Why? Because Michael Moore has adopted their tactics of using somewhat out of date anecdotes without any real data. At the least he’s made a teeny TV celebrity of Stuart Browning who’s now been on shouting matches on cable twice according to emails he’s sent me. And then into my email box the other day plopped this review at the American Thinker from someone called Peter Chowka, who apparently doesn’t like socialism and the bunch of know nothing, greedy Americans who are apparently ready to abandon the paragon of market efficiency that is our health system, because they think that some other approach might just cover a few more people at a lower cost—I mean just because all those foreigners do it how dare anyone think that we Americans might? Here’s some of Chowka’s rant:

From start to end, SiCKO, the latest "documentary" from notorious writer and filmmaker Michael Moore, is a stunning example of the Big Lie. Almost shockingly devoid of fact and context, it’s instead based on highly selective, emotionally-driven, and deeply flawed anecdotes, strung together by writer-director-producer Moore’s trademark folksy, soft-spoken, whimsical personal narrative. SiCKO (the unusual capitalization is Moore’s conceit) is not a documentary at all, but a naked propaganda exercise on behalf of full-bore socialism. A better title for it would be Pinko.

Continue reading…

TECH: Google trying to use Sicko to sell keyword advertising

Does negative press make health care companies Sicko? The solution is to buy a Google adword…Yup, that’s the headline of a come-on post on the Google Health Advertising Blog!

Wonder if the “health advertising team” at Google isn’t trying a little too hard given that the folks working on the separate health project at Google have also been more than a little negative on the current state of the health care system (to say the least!). Mind you this approach did work (for Google at least) in the middle of the KP HealthConnect Justen Deal drama, when the KP PR team bought the words “Justen Deal” and put up an a Google adword explaining their side of the story.

Much more over at ZDNet. More from me on Sicko tomorrow, and no I still haven’t seen it yet!

POLICY: A roadmap for reform by Maggie Mahar

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Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of Money-Driven medicine: The Real Reason Why healthcare costs so much, an examination of the economic forces driving the healthcare system.

In its June
2007 report to Congress, MedPac (the
Medicare Payment Advisory Commission) highlighted one of the dirty secrets
of our healthcare system:  as a nation, we are currently spending billions
on drugs, devices, surgical procedures and diagnostic tests without
having a clue as to whether they are effective. The reason, MedPac explained:
we have very little “comparative-effectiveness research” that provides
head-to-head comparisons of various treatments for a particular malady.

Meanwhile,
the Medicare commission observes, “Many new services disseminate quickly
into routine medical care without providers knowing whether they outperform
existing treatments, and to what extent. For example, a recent study
showed that inexpensive diuretics may control hypertension as effectively
as expensive calcium-channel blockers (ALLHAT 2002).”

One might think
that the FDA would require that a manufacturer show that its new drug
or device is better than existing treatments—at least for some patients. 
After all, new medical technologies are almost always more expensive,
so wouldn’t you think they would have to be “improved” in order
to be “approved”?

Think again.
That’s not the FDA’s job. The FDA exists simply to decide whether
the benefits of a particular treatment outweigh its risks. Thus, in
order to pass FDA scrutiny
manufacturers need only test their product against a placebo—which,
as MedPac notes, is what most do. In other words, they demonstrate their
treatment is “better than nothing.”

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THCB Reader mail

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Journalist Maggie Mahar, the author of "Money-Driven Medicine" and a
frequent contributor here at THCB, begs to differ with Matthew’s
lukewarm review of Sicko. (Theme: "Will Sicko Hurt more than it helps?") She emailed in to say:       

"I think that the movie will help push healthcare reform forward–in part because the filmis controversial … Focusing on the middle-class underinsured rather than the uninsured 
was, I think, a very shrewd move on Moore’s  part, and I don’t think the Cuban finale hurts him)." 

Skeptic disagrees about Moore’s picture. He had the following comment:

"Whether or not he realizes it, Moore has become a useful idiot for some
of the most reactionary interests in health care … I predict this film will be as effective in helping the
medically underserved as “Fahrenheit 911” was in preventing the
re-election of George Bush in 2004."

Peter Chowka, the author of an early review of Moore’s film in American Thinker ("Prepare to be sickened by Sicko"), that provoked a fair amount of heated discussion in the blogosphere obviously didn’t like the film very much. But he emailed in to say the following:

"My disagreements with Moore aside, I have to hand it to him for stoking
the discussion and debate about U.S. health care policy to
unprecedented levels, certainly a degree not seen since 1993-’94.
Hopefully, I (and I know many others) will have future opportunities to
delve more deeply into the core of the issues that Moore and his
supporters are highlighting, as the issues continue to emerge and, we
can hope, become more clearly defined."

Meanwhile, Mona writes in to tell us about OutofPocket.com, a start-up that seeks to use the power of social networking to shed light on
the weird world of health care pricing.

"I wanted to let you know about a grassroots
consumer initiative for consumers to look up true prices
for common health care services.  The website consists of
consumer-contributed data and CMS payment data for common Medicare
services.  As a consumer advocate, my goal is to achieve critical mass
for consumer participation in this initiative. I believe consumers have
the power to positively influence the future direction of healthcare
and encourage healthy competition in the industry.  In order to
accomplish this goal, we need your help promoting www.OutOfPocket.com to get the word out."

In response to last week’s THCB post on Los Angeles OB-GYN Dr. Gil Mileikowsky and his fight to win protections for doctors who report medical errors at their hospitals, Bart Lee of Spiegel, Liao & Kagay writes.

"John Irvine’s note is most welcome. We represented Dr. Mileikowsky. Charly Kagay of this office handled the appeal. Dr. Mileikowsky’s Black Box idea is a system of anonymous and objective review. 

Presently "Peer Review" as a discipline is all too often biased. These biases go largely uncorrected because of the immunity provisions of the Health Care Quality Improvement Act, which has not improved the quality of health care. There is a sword available, by a simple amendment, to untie this Gordian Knot: My suggestion, which follows, as to the best and quickest way to fix HCQIA’s immunity problem, is  … (Comment edited for length. See full version here.) …  to amend this section:

"A professional review body’s failure to meet the conditions described in this subsection shall, in itself, constitute failure to meet the standards of subsection (a)(3) of this section."

"That is, take out the "not." A hospital that that runs a kangaroo court should not get to take advantage of its own wrongdoing. Each and every National Practitioner Data Bank report that results from a peer review body that fails to meet the specified conditions should not be privileged, should be enjoin-able in equity in state or federal court, and should give rise to a damages action including attorneys’ fees. Each and every kangaroo court "peer review" should not enjoy immunity from any damages causes of action."

If you missed Dr. Mileikowsky’s original YouTube appearance, you can find it here … [Uber]

Dr. Thom writes in to opine on Maggie Mahar’s excellent essay – "Do Non-Profit Hospitals deserve their tax breaks?"   

"I am a for profit doctor with privileges at a not-for-profit institution.  I do my share of unassigned calls, see uninsured patients and I practice with the largest private provider of Medicaid services in my state.  When someone comes in for care and can’t pay, I charge him the full amount on the front end and mark down the charges or write it off completely on the back end.  Rarely do folks who can’t pay get sent to collections.   Our hospital, on the other hand, has what our consultants have told us as the most aggressive collection policy they have ever seen, profit or not."

Meanwhile, reader speculation that start-up social networking site PeerWisdom might be changing its name at some point soon turns out to have been exactly on target. The company’s Jude O’Reilly writes to us happily:

"As if on your cue, we’ve just announced the change of our name from PeerWisdom to Trusera. (We’re not giving up on being wise, just using wisdom in our name!)  PeerWisdom was intended to get us through our early funding." 

In response to Scott Shreeve’s post arguing that recent reports of the death of the consumer-driven-health care movement (gulp!) may be slightly exaggerated, B.E. Rodin writes:

"There are few other industries where information on product quality and cost are so difficult to obtain.  Of course, this is compounded by the third party payment system.  When someone else foots the bill, we have no motivation to efficiently spend limited dollars.  The second key ingredient in consumer driven health care is to have consumers be responsible for allocating limited funds to spend on their health care.  Perhaps consumers will then routinely question the effectiveness/necessity of medical treatments and look for alternatives.  Perhaps they will start to live a lifestyle which promotes health, rather than assume that there will be a pill to cure almost anything that goes wrong."

Chris Johnson writes to weigh in on the debate over the merits — and lack thereof — of health savings accounts.

"I’m a self-employed physician with an HSA, and even I have
trouble using the thing effectively. In spite of the inside knowledge I
have of the system, it’s just as hard for me to find out how much
things really cost as it is for anyone else."

Meanwhile, insurance agent Chris – presumably no relation – writes in on
the controversy surrounding the business practices and standards of certain health insurers.

"I’ve researched the Mega and Midwest plans and honestly cannot find
a lot of room for those companies to get out of paying what they say
they will. I think the problem is that agents tell people they have
more coverage than they actually have.  My personal experience has been
that I have NEVER been encouraged to make the plan appear better than
it actually is…" 

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QUALITY: Back surgery request

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A great friend of mine is looking for back surgery information. As we know this is one area where not much is know about what works. Any ideas? If so please comment:

I’ve been dealing with a couple of herniated disks in my lower back for the past
2 years.  Over that period of time, I’ve tried treating the pain with epidural
steroid injections, physical therapy, manual manipulation and deep tissue
massaging, acupuncture, and lots of fun pain "cocktails".  These treatments have
provided, at best, temporary relief from the pain.  And lots of crazy
hallucinogenic dreams! 

Last week I had a discogram (a diagnostic procedure to determine how badly
damaged the disks were), to enable my doctor to determine what type of surgery
would be best.  Talk about hallucinations… that Demerol is good stuff!  We
went through the results last night and, unfortunately, it’s worse than we
thought it would be.  One of my disks is so badly torn across the posterior of
the disk that procedures like a diskectomy or laminectomy won’t work.  I have
the option of either full disk replacement (which is a pretty involved abdominal
procedure where they replace the disk with a stainless steel mechanism that
works on a ball & pivot system… call me the "bionic woman") or a procedure
called an Intradiskal Electrothermal Therapy (IDET) that essentially cauterizes
the outside of the disk to kill some nerve root endings and seal off the tears
in the disk.  It sounds pretty high tech and cool… if it weren’t going to be
performed on me! 

My understanding is IDET is a short-term solution and, eventually, I’ll
need to have my disc replaced.  But I’ve also learned that there are a lot of
new disc replacement technologies in the works so it’s in my best interest to
hold off on the more involved procedure.  That said, I’m leaning toward the IDET
option since it seems the least risky course of action and could potentially
reduce my pain immediately with no major side effects.  Unless you count the
humiliation and trauma from having to wear a stiff plastic corset for 10-12
weeks after the procedure? If you know someone who has had disc replacement surgery or an IDET
procedure and is willing to talk with me about their experience, I’d really
appreciate it!  Also, if you have any recommendations of really good surgeons
for my second opinion, I’m looking for referrals, too. 

JOB POST: Practice Leader, Knowledge Services

Kaiser Permanente’s Care Management Institute (CMI) is a unique,
pioneering institution with a mandate to drive, fund, and catalyze care
management activities throughout our non-profit HMO. CMI strives "to
make the right thing easier to do. The Center for Health Care Delivery is creating a new Knowledge Service/Evidence unit. The Practice Leader, Knowledge Services will focus on Knowledge Services and guideline development. In conjunction with the CMI Manager, CMI Evidence Methodologist and Medical Director, Center for Health Care Delivery, this position initiates, coordinates, and facilitates the development, revision and dissemination of national evidence-based guidelines  designed to improve member outcomes and organizational performance throughout KP.Responses to: Ca**********@**.org.

PLEASE remember to include THCB JOB BOARD in the subject of your email.

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