Dig into this story — It’s a juicy one "E-mail leads to doc lawsuit in Jefferson Health System"
Sounds like there’s a little war over patient ownership going on…just in case you forgot your hospital econ 101.
Above the Fold
QUALITY/CONSUMER/TECH: Health — On Demand by Pat Salber
Pat Salber writes The Doctor Weighs In, and she has some pretty interesting thoughts about this consumer health schtick. I cross-posted here but go check out her blog too!
The Internet has changed the way we do so many of life’s routine activities. We shop on-line for clothes, food, birthday presents (thank heavens–no more going to the post office), insurance, dates, and new friends. The list of things we can do and get on the net just goes on and on. PEERtrainer (www.peertrainer.com) has joined many other websites as a convenient, fun way to meet people with common interests and goals. It offers peer support and accountability with 24/7 convenience, and if desired, anonymity. And the Internet is changing the face of health care as well. I belong to Kaiser Permanente, an integrated health care system that makes it easy to make appointments on-line as well as to refill and have my medications mailed to me. I can get my lab results via a secure website and I can communicate with my physician via email.
But I never thought I would be able to get health and wellness services on the web. This weekend, I was at a medical conference and learned about an amazing new website: www.keepyoursight.com. A young ophthalmologist, Sean Ianchulev, described how his company, Peristat Group, has developed a way to screen for glaucoma on-line. Now, I guess I am a little out of date. My first thought was, "How are they going to deliver that little puff of air to my eye via the web?" Of course, that is not the only way to screen for glaucoma anymore. Rather, machines that test your peripheral vision have replaced the air puffs in many health care settings. This type of testing is called perimetry. The Peristat Group has figured out how to mimic what on-site perimetry machines do — on-line. That means, anyone can get screened for glaucoma in the privacy of their home anytime they want. It’s a bit complicated and takes some practice, but the site takes you through some simple instructions and then allows you to practice until you get the hang of it. Dr. Ianchulev tells me they built algorithms into the on-line test that help them weed out tests that are not performed properly. He also tells me they are developing an on-line test for macular degeneration, one of the leading causes of blindness in the US. Imagine, as this technology gets better and better and the test-taking gets easier and easier, glaucoma testing, testing for macular degeneration, and who knows what else, will be available to people “On Demand.”
As we move into an age where consumers are being asked to shoulder more and more of the financial burden of health care, I suspect we will see even more innovation in the delivery of services. The FDA recently turned down the request to have statins, very effective cholesterol-lowering drugs, available over-the-counter (OTC). Opponents of OTC statins worried that consumers would not recognize the rare, but serious side effects of these relatively safe medications. However, such dangerous drugs as aspirin and acetaminophen (e.g., Tylenol) have been available OTC for decades. I can’t tell you how many people I treated for overdoses of these benign drugs during the years I practiced emergency medicine. I think the argument of having to protect the public is one that will not hold up in the long run. Combine the use of home testing electronic devices with great interactive web-based programs, OTC availability of cholesterol-lowering drugs and blood pressure-lowering drugs, and on demand lab testing (available in many states) and you now have a way to get treatment of these common conditions to millions of people who are now untreated or undertreated…and for a fraction of the cost.
I think innovations in health care delivery, such as these, are very exciting, but also threatening to the same folks who have been promoting "Consumer Directed Health Plans" as the way to save the disintegrating American health care "system." But, hey, if I have to pay for it out of my pocket, I am going to get what I want, how I want it and when I want it. If I can get it for free on the net in the middle of the night, I say, bring it on. “Health On Demand,” — now this will usher in the age of real consumer directed health care.
THCB: Shhh…go back to sleep
Life will be vey quiet here today while I get some other stuff that’s been stuck in my queue done.
HOSPITALS/TECH: Is the kiddie porn hysteria going too far?
You would expect Children’s Hospital in San Diego to be very, very nervous about anything to do with porn. After all, this is the place where apparently a nurse and a tech roamed free taking pornographic pictures of children, molesting them, and spreading the pictures on kiddie porn sites.
Wayne Albert Bleyle, 54, who was arrested March 8, has pleaded not guilty to molesting five patients. He also pleaded not guilty to distributing pornographic pictures of patients on the Internet. Christopher Alan Irvin, 32, a nurse who was arrested April 15, has pleaded not guilty to charges of molesting a 4-year-old girl and distributing child pornography.
And speaking from experience I know about second-hand, people do very, very foolish things on their work computers. But it seems that the latest news from San Diego Children’s may be a little over the top. So far three doctors have been suspended because one of them, while logged on to the hospital’s system from home, visited a porn site
Hanscom said using the access code to look at pornography would violate hospital policy whether the images were of adults or children. The access appears to have been on a home computer. Improper use of the code was discovered as a result of more vigorous auditing adopted after the arrests of the two hospital employees.
Now the key issue we don’t know is what type of porn site—and there is a huge legal as well as ethical difference between the secret chat-rooms where paedophiles trade pictures, and the Playboy online type sites. And of course whoever was logged into the hospital’s Internet access was dumb, dumb, dumb not to log out and go off to their own local ISP before looking for smut online. But let’s get real. A huge proportion of Americans look at porn online, and doctors are no different.
Assuming that this is a case of legal behavior at home, that was inappropriately sourced through the wrong ISP, you have to think that handing this over to the “Internet Crimes Against Children Task Force, which includes local and federal agencies” and suspending three physicians and putting it in the newspaper, may be an over-reaction.
Did the hospital management not think to first have a quiet word with the physicians concerned to find out a) which one of the three was the guilty party and then b) have their IT staff and lawyers investigate what they saw, and discover whether their behavior was illegal or just stupid. And if was only the latter, then take some administrative action against them before ruining careers and getting law enforcement involved. Which if it was the former would clearly happen anyway.
Meanwhile, a reminder to all of you out there, make sure that you keep a private Internet connection, email server, et al away from your employer.
TECH/CONSUMERS: It’s care delivery that matters most
Here’s my FH editorial today….
This week two very different healthcare conferences rolled through San Francisco. One was about Consumer-Directed Health Care and was a cross between a capitalist land-grab and a political pep rally for HSA-backers and Canada-bashers. There are clearly interesting ideas from many start-ups as to how to better serve consumers , and plenty of new initiatives from bankers wanting to get at the new accounts being set up within health care. Google’s announcement of its new “Co-op” service that includes a “Health” component, and Intuit’s deal with Ingenix show that big time consumer companies are viewing this movement seriously.
Later in the week the National Patient Safety Conference saw clinicians discussing the issues of medial errors, nursing and clinical efficiency, and how to use technology to turn around provider performance. That is clearly a much bigger and even more intractable problem than making health care more consumer friendly. It’s also a movement that has been going on for more than twenty years, and we are really only seeing marginal improvements. Health care has many problems, but clearly the care delivery coal-face is where most health care money is spent, and where we have the most to change.
POLICY/PHARMA: Cato calls the Republicans on the Part D deceipt
I approve of government programs done well. Michael Cannon doesn’t approve of them done much at all. We both disapprove of them being done expensively and then having so-called Conservatives in power lie bold face about their costs and enrollment rates. Yup, I’m sending you over to the Cato Institute blog. That might be a first for TPM Cafe, but it’s a great explanation of what’s wrong with Part D.
(Also posted at TPMcafe)
CODA: I haven’t made it thorugh Kling’s book yet, and I had a real problem with Cannon’s — as it missed the point so badly that I didn’t think it was worth reviewing. But with Radley Balko keeping up on the drug war stuff, Cato remains the thinking man’s right wing think-tank.
PHYSICIANS/BLOGS: Disheartened? Maybe
I love people commenting on THCB, and 99% of the comments are very, very thoughtful. But I am a little dismayed that while only one person wants to comment on my long piece on the individual insurance market, one other on VC in health care (and that someone I wrote about clarifying a point she made) and none on my experience at the consumerism conference—28 people have something to say about a malpractice study I just point to!
People, malpractice is one percent of the dollars, and it’s about 17th on the list of major health care problems and issues we face in this country! It’s the abortion issue of health care—polarizing way way beyond it’s importance. <sigh>
POLICY: talking about the inefficiencies of the insurance market…
A Commonwealth Fund study from HSC in the latest Health Affairs reminds us that employees in small firms pay 18% more for health insurance when adjusted for value of plan adjusted premiums. Here’s the full Health Affairs study
Meanwhile, to the surprise of absolutely nobody that’s been paying attention, another study in the same Health Affairs shows that increased competition in the Medicare risk/Advantage program (i.e. the private plan part of it) is associated with greater use of advertising targeting healthier patients. More from PNHP’s Don McCanne on that.
PBMs: Is the edifice crumbling–not yet!
Conundrum—It was reported in their most recent 10K that what Medco got in rebates from manufacturers went down, and that really hit profit from that sector of their business in the most recent quarter. But their overall profits went up? How did they manage it?
Well I know (and told a private client all about it in research report) and have given you some hints before about where they make their money. But now Barbara Martinez at the WSJ has figured it out—their margins on generics are huge. And of course they control that channel by pushing their clients into mail order where they can make the generic substitutions as soon as the rebates go away. So the more generics they sell, and the more mail order they sell, the higher their margins are —even if they keep less of the rebate on the branded product.
And, as the WSJ article says, luckily for them their clients are too dumb to figure it out. (Other than Horizon Blues of New Jersey which is suing Medco)
But wait there’s a little more. Remember last year? That’s when the trade association of the big PBMs (PCMA) put out a report explaining what great savings mail order provided for purchasers of drugs. But the entire report neglected to mention that mail-order pharmacies are significantly more profitable then regular pharmacies, and it further neglected that the owners of the major mail-order houses are, of course, the big PBMs.
CONSUMERS/BLOGS: CDHC Conference
Dmitriy did a nice job at his talk at the CDHCC meeting yesterday. You can see his slides here
I was the skunk in the room on a couple of panels. I asked a “question” at the payments and financial services panel, which basically said that HSAs were going to turn doctors into collections agencies….and got surrounded by lots of people afterwards who either agreed with me, or who told me that they were on the point of building the real-time credit guaranteeing, deductible adjudication network that was going to save physicians, and guarantee them that the patients with HDHPs actually pay their bills. They’d better be right, or else the doctors will start thinking that single payer, but one that at least guarantees to pay, is a pretty good alternative!
I was not the only skunk in the room on the Sally Pipes/Grace-Marie Turner debate (!) which I pointed out was as much of a debate as the Republican Convention. One questioner stood up and said that the pro-HSA crowd (which he was on) would have to prove that they weren’t just about employers cost shifting to employees, or they’d lose the ideological battle. Too bloody right—unfortunately the data is in and that is exactly what’s going on. The PRI guys (Graham and Pipes) want to go to meetings to combat State Senator Sheila Kuhl’s call for single payer—what they are confused about is why the single payer guys think that HSAs are a godsend for their cause. Apparently they think everyone wants to have an HSA and take part in health care “ownership”.
I tried to be a moderate and merely pointed out that the ideologues in the HSA movement are treading on very dangerous ground as Americans love their employer-based insurance and know that there’s not much to replace it with. Just wait till they find out how dreadful life is in the individual market!
