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QUALITY: The herniated disk story

• 22

Medpundit has a pretty good explanation of the recent study about herniated disk surgery. Basically it works, but if you wait two years, then the results are about the same as non-surgical treatment—roughly 70% of people get better, and there doesn’t appear to be any long-term harm from delaying surgery. As I have someone very close to me with a current case of extreme back and leg pain from a herniated disk, I’m very interested in the study, and actually more inclined to suggest surgery (especially arthroscopic) sooner rather than later. But in this case the patient, doctor and other advisors are more in favor of waiting it out.

So on a global level it’s more cost-effective not to do the surgery. But on an individual level it probably lessens the pain—and the pain is close to unbearable, and if you have to put up with it for several months, then surgery is probably an option the patient will want.

Note that this is only the case for herniated disks and not lots of the other back issues for which surgery is probably ineffective–but still done at a very high rate.

The good news is that ten years after AHCPR (the forerunner to AHRQ) was decimated by daring to discuss back surgery, we’re getting studies out about this type of issue. Even, as Medpundit points out, it’s not a great study and it’s very, very hard to do studies about this type of intractable medical problem.

CODA: One slightly disquieting anecdote. I asked a local back specialist (non-surgeon) what the best way of doing surgery was (open or athroscopic). He said that the choice depended mostly on the training of the surgeon! Er…shouldn’t the surgeon be trained in the most advanced manner? (I expect those who know to chime in here)

POLICY/POLITICS/PHARMA: PhRMA sends the D out on the field

• 30

Even thought the White House will likely veto any change to Part D, the WSJ has started playing desperate defense on behalf of PhRMA.

Apparently if we impose government price controls, it’ll cripple R&D and no new drug will ever be developed. On the other hand, they also trot out the “fact” that Part D as constructed now means that the private sector has the ability to lower prices below those that the government could get. Of course we’ve heard all this before, and we all know who wrote Part D and in whose interests it was written.

But what I wonder is how can the WSJ’s Jane Zhang hold those two contradictory thoughts in her head without smoke coming out of her ears?

Meanwhile, here’s the NY Times on big Pharma’s attempts to buy its way out of the problem. It’ll certainly make some former Democratic staffers much richer!

PHYSICIANS: The New York Times–desperate to fill column inches

• 5

When I think about all the problems in American health care, many of them the result of the political and clinical choices made by “older and middle-aged physicians (like myself)” (“Myself” being the author of the piece, Dr Erin Marcus from Miami) I can’t say that the non-formal attire worn by some young doctors  is exactly in the top 5000. In fact wearing a tie, as she (I think Erin is a she) points out, is actually harmful as they collect bacteria—so the chippie with the low cut top is better for the patient than the stuffy old doc wearing the tie!

But honestly, has the paper of record got nothing better to say about physicians, and no one more interesting than Dr. Marcus to invite to write about them? I’m reminded of open sores…..

Happy Thanksgiving!

TECH/HEALTH PLANS/QUALITY: Lonny Reisman, Active Health Management transcript

• 5

Here’s the transcript from the podcast I did with Lonny Reisman, a week or so back. Really interesting stuff for those of you interested in the future of patient care management.

Matthew Holt: So welcome to another forecast here at The Health Care Blog. I’m Matthew Holt, and today very exciting that we’re talking with somebody’s who’s really been a technology pioneer and a medical pioneer in developing tools for active health management, and surprising enough, his company is called Active Health Management and I’m talking with Lonny Reisman. Lonny, how are you today?

Lonny Reisman: I’m well, thank you. How are you?

Matthew: We’re doing pretty well over here. One of the first fall and somewhat foggy days in San Francisco, but at least we’re not going to endure that terrible New York winter you’re going to have to go through [laughter]. Anyway, let me very briefly give a sense to, in essence, what your organization does. And there are a couple of things that people who may or may not necessarily have heard of Active Health Management should know. First off is that you are in the business of taking data, all kinds of different data about medical information about patients, putting it all together and spitting it back out and using it to try and help and inform and change medical decisions by those patients and physicians. And the second one is that you’ve been so successful at that, that last year, Aetna decided to write a very big check, $400 million to buy you, and now you’re part of that large insurance company. So with that it’s a very brief introduction. why don’t you say a little bit about what Active Health Management does, how you got started, and what kind of impact you’ve been having in the healthcare system and the part of it you’re specializing in.

Lonny: Sure. Why don’t I start with my background, which will give you a sense of how we have come to be here. I’m board-certified in internal medicine in cardiology, I’m a physician, and during the 1990s I was leading a bit of a dual existence. I was practicing clinical medicine here in New York City, had a fairly typical practice, but I also was consulting with a large human resources consulting firm, William M Mercer, and was charged with evaluating health plans around the United States, mostly from my perspective on the basis of quality but obviously the premiums and the costs associated for those health plans was a consideration as well. In considering what I was experiencing as a practitioner and what I saw as a consultant evaluating health plans, saw an opportunity to better take advantage of clinical data that were available in the managed care world which weren’t being fully exploited. So specifically as I visited health plans I saw that they had the capacity to collect drug information, laboratory results, information about procedures and diagnoses and basically had the thought that if in fact that information could be used to support doctors and patients in making decisions, that in fact we’d be able to raise the bar with regard to the level of clinical excellence being provided to patients all over the United States. So fundamentally, the observation that I made, which ended up being relevant to what I was experiencing as a practitioner was that to the extend that the care that was being provided by me and others was fragmented, specifically I didn’t necessarily know what other doctors were doing to my patients or for my patients, to the extent that all of the information about a patient or much of it could be aggregated at the health plan level, we decided to take advantage of that.

The other component of Active Health, which again sort of derives from my own experience and perhaps insecurity, is that I recognized early on in my career that it’s very, very difficult to keep up. So there are thousands of articles, relevant articles, published yearly and the issue is how does one not only read and assimilate and remember those articles, but how does a physician relate the information in an article that they’ve read to the particulars that relate to a patient sitting in front of that doctor during the course of an office visit.

Matthew: They can’t is basically the answer, correct?

Lonny: Can’t do it, right, exactly. It’s just too much. So the basic notion and this is as true today as it was in 1998 when we started the company was if in fact you could provide the treating physician with more clinical data on the member than they have access to—again the patients frequently see multiple doctors—and then if you could expose those data to thousands of clinical rules that represent incontrovertible standards of clinical excellence and use technology to highlight discrepancies between what was actually happening to the patient as manifested in their data as opposed to what should be happening as displayed in the literature, we in fact could pinpoint changes that needed to be applied to individual patients by doctors that related to everything from preventive care to diagnostic services to therapeutics to follow-up, and basically started the company with the notion that we would have those data, have a technology that would analyze those data and communicate first with doctors and then over the years with patients in order to again introduce this level of consistency to the healthcare system. And from there we’ve evolved into other sort of disease management like capabilities which I’ll elaborate on. But the fundamental premise behind the company is what I’ve articulated.

Continue reading…

HOSPITALS/TECH: VISICU

• 2

My article about VISICU, complete with allusions to rockumentaries, is up at Digital Health & Productivity

A new star’s emergence meets with wild success.
Then problems emerge and it looks like the dream is over, until he or
she makes a storming comeback. VH1 fans will recognize the Behind the Music format, but this might be the story of VISICU.

VISICU’s technology creates a remote control
room–the eICU–with video links and feeds from equipment in physical
intensive care units (ICUs) and hospital IT systems. All this
information goes through a rules engine that delivers alerts to the
doctors and nurses staffing the eICU. VISICU says its solution of
remote perpetual management, based on the alerts, leads to better
patient outcomes compared to traditional ICU management in an era of
intensivist shortages. Continue

 

HEALTH PLANS/TECH: Full text of Andrew Wiesenthal (Permanente Federation) interview

• 2

Here’s the full text of my interview from last week with Andrew Wiesenthal of the Permanente Federation–mostly about the HealthConnect project and attendant controversies!

Matthew Holt: This is Matthew Holt at The Health Care Blog and tonight at rather short notice I am lucky to have an interview with Andrew Wiesenthal who is an executive director in the Permanent Federation which is the umbrella group that oversees the entire Permanente Medical Group in the different regions of Kaiser Permanente. Andrew contacted me this afternoon as he had seen a number of the postings on various blogs on some of the issues that have been going on with Kaiser. And I thought it would be a good chance to have a discussion with him about many of the issues, some of which have been raised in the last week about Health Connect and some others. So, Andrew, thanks a lot for agreeing to take the call. I know you are in the back of a cab there and hopefully we can have a decent conversation. So could you just give me a very brief thumbnail sketch of your role at Permanente and a little bit on how the Permanent Federation is organized.

Andrew Wiesenthal: Sure, I am a pediatrics infectious disease physician and I began my career as a member of Kaiser Permanente as a member of the Colorado Permanente Medical Group something over 20 years ago. I took care of patients and also had responsibility for quality improvement and other things in my medical group in Denver, Colorado. And, as part of that, almost 20 years ago I began to clearly see the need for an electronic health record in order to gather the kinds of information we want them to have so we could measure our quality and improve it. Ultimately I was the Physician leader for the development of what we called the CIS or Clinical Information Systems in Colorado. We finished that development and deployment work in 1998. Kaiser Permanente in Colorado does not own and operate Hospitals so the record was in the ambulatory setting. But this did serve at that time about 600 physicians and approximately 400,000 members of the Colorado regions. That was what it was doing at that particular point. Basically the physicians, nurses and staff of Kaiser Permanent in Colorado were essentially paperless from that point forward.

Continue reading…

POLICY: Maryland plan mandates coverage

• 14

Maryland is considering a plan that would require residents to purchase health insurance. Very similar on the surface to the Massachusetts plan, but with a few key differences.  Via Balt Sun:

The plan would be a radical change from the current system of employers
choosing which health plans to offer to workers. It would set up an
insurance exchange where individuals could choose from any plans
offered by insurers and keep the same coverage when moving from job to
job.

The plan wouldn’t apply to large employers, but the cutoff on employer size hasn’t been set.Employers would pay much of the cost, with each employer setting a
dollar figure it would contribute toward the purchase. And the state
would provide a subsidy for lower-income workers.   

The Maryland Health plan doesn’t include any mandate on employers –
making it different from the Massachusetts law. But Cowdry said
"individual responsibility would put greater pressure on employers" to
"be in the game" by contributing to insurance coverage.

If the idea actually goes anywhere, Maryland would become the second state to embrace the idea of mandated coverage.  Given the amount of attention and credibility Romney has gained by taking credit for coming up with the idea, it seems inevitable that more states will launch similar experiments. So who will be next?  In California, Arnold’s office has been hinting that a major health care policy announcement of some kind is on the way. I wonder if they could be planning something along similar lines. — John Irvine

BLOGS/HEALTH PLANS: Why we love Roy Poses!

• 1

Over at Health Care Renewal Roy Poses notes that the Annals of Internal Medicine has an article by a little known Columbia University public health professor (well, actually not one, but you’d never know) with the name J. Rowe which appears to promote pay for performance. Roy notices that a certain major national health plan until recently had a CEO with a very similar name which might possible benefit from P4P.

Roy wonders if they are, perchance, related?

HOPSITALS/HEALTH PLANS: You’d think Kaiser’s had enough bad publicity lately, but then again

• 8

The city of  Los Angeles. is filing patient `dumping’ charges against Kaiser Permanente. Obviously there are plenty of hospitals dumping patients onto LA’s Skid Row, and obviously the way our society deals with elderly people with dementia, (and younger ones with other problems too)—by leaving them out on the streets—is a disaster. We clearly need a national health and social services system to deal with these issues,a nd Kaiser (and the rest of the health care system) should throw its weight behind us getting one. But given that we don’t the city is just picking the best example, which happens to be from an organization with deep pockets. 

And I’m sure that the Kaiser staff meant for the elderly patient still wearing a hospital gown to make it from the taxi into the Union Rescue Mission (rather than as the video shows literally wonder the wrong way down a busy road, not even on the sidewalk). But for KP, this is just a damning indictment:

The Los Angeles city attorney’s office filed false-imprisonment and dependent-care-endangerment charges against hospital giant Kaiser Permanente on Wednesday, the first criminal prosecution of a medical center accused of “dumping” patients on skid row. The charges stem from an incident earlier this year when a 63-year-old patient from Kaiser Permanente’s Bellflower hospital was videotaped as she left a taxi in gown and socks, and then wandered skid row streets.

<SNIP>

The day she was discharged, March 20, hospital staff members wrote on her chart that she was “non-talkative,” “forgetful” and “disoriented,” according to court documents.”Despite these findings,” prosecutors said, “the Kaiser Bellflower staff made no other efforts to assess or treat her medical condition.” Instead, the documents say, hospital staff “summoned a taxicab and directed the taxi driver to transport Ms. Reyes to skid row, approximately 16 miles away…. [She] was literally rushed out of the hospital and into the taxi even though the hospital staff could not locate her clothes…. [T]hey escorted her to the taxi without any pants, even though Ms. Reyes expressed concern about her clothes.” Court documents allege that Reyes was not told that she was being taken to skid row.After Reyes arrived at skid row, Union Rescue Mission staff members worked out a special arrangement so that she could remain in the facility during the day rather than check out the next morning and re-apply for a bed later in the day. But three days after her discharge from Bellflower, according to the documents, Reyes “lost consciousness in the bathroom of URM, falling and suffering head trauma.”Jeff Isaacs, head of the city attorney’s criminal division, said Reyes was subsequently hospitalized at Los Angeles County-USC Medical Center, where she was diagnosed with pneumonia, anemia and dementia, a progressive brain dysfunction, and remained in the hospital for at least 45 days. A guardian has been appointed to protect her interests, Isaacs said.

And the cynics would point out that if the patient had spent those 45 days at Kaiser rather than LA County, then they, not the taxpayer, would have paid for it.

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