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QUALITY: The patient satisfaction trap by John Irvine, with rant from Ann Farrell

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So in FierceHealthcare today my colleague John Irvine wrote this

Some hospitals have argued for years that patient satisfaction scores can be misleading when it comes to gauging the quality of the healthcare services they receive. After all, patients are only human, aren’t they? And can easily be swayed by factors that have little if anything to do with the true quality of care. A new study out in the Annals of Internal Medicine appears to back this view. RAND Researchers and a team from the University of California Los Angeles surveyed 236 elderly patients, asking them to rate the quality of the care they had received. The average response was 8 out of 10. Follow up on patient records determined that patients received the recommended care 55 percent of the time. Now those numbers may seem relatively unimpressive, but they are evidence of a something that many providers have intuitively believed. It will be interesting to see how this plays out.

That apparently struck a nerve with FH reader Ann Farrell. She wrote to me about this problem, and one senses a little frustration in her voice!

It drives me NUTS when people (smart people and even payors) confuse satisfaction with quality of care  – two things that are NOT THE SAME, and in fact many times not correlated.  In some studies patients getting ongoing excellent care are exposed to the health system more than their healthy counterparts thus have more opportunities for service gaps. People in this study’s satisfaction with plans decreased the more they received treatment, as good as it may be clinically. 

Quality of care has to do with the addressing underlying problems, i.e. getting diagnosed properly then improving status of  medical condition or receiving palliative care if no improvement possible .For example, my diabetes is being treated with best practices leading to optimal outcomes, lack of complications, etc. We know from recent market data that this only happens 55% (if my recall correct) of time. Consumers are by and large clueless about the actual quality of care they are receiving, and many unaware of the patient safety data, i.e. we’re killing close to 100K people a year, which is not only bad quality but introducing medical problems, e.g. nosocomial infections, or actively killing patients, e.g. drug errors. 
 
Quality of care and patient safety have nothing to do with service or satisfaction, which is often based on parking, food, access/TATs and perception of care providers, “does someone answer my call bell quickly when I need them?” You can have great service and woeful quality, or visa versa. When I worked with benchmarking data University Hospitals has better quality outcomes than community hospitals they competed with so patients tolerated bad service, i.e. waiting for hours in waiting rooms, etc. Now specialty hospitals and some community hospitals are delivering comparable care and differentiating based on improved service. So the fact that people still use the terms interchangeably is baffling. MOST patients haven’t known what the quality of their care is – the Internet is changing that in terms of better access to care standards and evidence.
 
Sorry, as you can see this struck a huge chord with me, we have to know what problem we’re tackling to solve it.  The industry confuses this.

For some reason the issue of quality, waste, doctors not providing optimal care, etc seems to be a contentious one on THCB. I personally believe that fixing the consumer satisfaction part of health care is easier to do and equally necessary than fixing the care process. But they are separate things (both of which the system deals with very badly). But what do I know? Feel free to have at it in the comments!

BLOGS: Email problems again

I yet again had email problems between 6 am and 11.27 am PST today. If you sent me a vital email during that time, please resend it. Matthew

QUALITY: Games For Health

There’s a Games for Health Day on May 9 in Los Angeles, California. It’s on the subject of Games for rehab, pain distraction, and health promotion. Want to know more? Games For Health

HEALTH PLANS/POLICY: RAND shows that HDHPs will only havea modest impact

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There’s an important article out in Health Affairs showing that, as has been suggested on THCB many times, contrary to some (and it is only some) of the HDHP/CDHC advocates rantings, the move to lower premium higher deductible health plans even with premium subsidies for the poor will have relatively little overall impact, and certainly won’t change the uninsurance numbers much. Here’s the Press Release and the money quote:

Price subsidies have only modest effects on overall participation in the individual health insurance market, RAND Corporation senior economist Susan Marquis and coauthors report in a Health Affairs Web Exclusive published today.

“A 20 percent [premium] subsidy would increase the number of subscribers in the individual market by 5-11 percent and decrease the number of uninsured people by 1-3 percent,” the researchers report. That comes from 1-2 percent more potential purchasers deciding to buy insurance and about 15 percent fewer current enrollees dropping coverage, as a result of the 20 percent subsidy.

I’ll be back later when I’ve read the article.

UPDATE: Damn, didn’t even get a chance to read this and I’ve already been interviewed about it. I must be getting famous. Wealth surely to follow?

JOBS: Positions at Telecare (Alameda, CA)

My former i-Beacon colleague Phil Chuang is now CIO at Telecare, a mental health management company in Alameda, CA (Bay Area). He is looking for warm (and hopefully bright bodies). Phil would be a great person to work for.

He’s trying to fill a couple of full time career positions right now  A senior project manager and an applications engineer (mid-to-senior level).  He’ll also be adding business analysts, help desk and network technicians, and programming staff (.Net skills) after the start of the fiscal year on July 1

If this is you or you know of anyone good in these areas, please have them email me.

TECH/PHARMA: Making use of patients while they wait

I have an an article in today’s Health-IT World about technology in the physician waiting room. It features a couple of interesting companies including Phreesia and VisionTree. I met the Phreesia guys in New York recently and played with the product a little. I think as a patient it would be fun and very useful. And it has lots of potential to help out doctors and their office staff. And of course, it’s a great venue for DTC. How the Phreesia guys handle that is to be seen, but frankly useful and not necessarily branded communications about conditions in the physicians’ wating room should be a win-win for everyone.  After all more targeted DTC is better, right?

Full Disclosure-Phreesia is an advertiser on TCHB. VisionTree isn’t. But I like them both! And as you may have guessed I’m not exactly getting rich off THCB advertising.

QUALITY: Middle-Aged Americans Sicker Than British

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Says here that Middle-Aged Americans are Sicker Than British. . Apparently at every class strata it’s true:

A higher rate of Americans tested positive for diabetes and heart disease than the British. Americans also self-reported more diabetes, heart attacks, strokes, lung disease and cancer. The gap between countries holds true for educated and uneducated, rich and poor. “At every point in the social hierarchy there is more illness in the United States than in England and the differences are really dramatic,” said study co-author Dr. Michael Marmot, an epidemiologist at University College London in England.

Part of the problem is that Americans don’t binge drink enough…at least I’ve always thought so and I think that’s what they’re saying here:

Britons have a higher rate of heavy drinking, but a higher percentage of Americans are obese.The researchers crunched numbers to create a hypothetical statistical world in which the English had Americans’ lifestyle risk factors. In that model, in which the English were as fat as the Americans, the researchers found Americans still would be sicker.

And the quasi-racist crap that certain Canada bashers put out about US outcomes being worse because of all our minorities—who have the temerity to be both poor and dark-sinned—skewing the numbers is also put to the statistical sword:

The new study showed that when minorities are removed from the equation, and adjustments are made to control for education and income, white people in England are still healthier than white people in the United States.

Now there’s a lot of pap in the article about how the US spends twice as much per capita as the Brits on health care and how come the results are so bad.  But as anyone reading THCB knows health and health care are only tangentially related, and you certainly shouldn’t expect a causal correlation between spending on one and good results in the other.

On the other hand this does raise a crucial question that’s very important to an extremely local audience for THCB. As I was born and lived in the UK for 26 years and have lived here for 17. So am I as healthy as a Yank or a Limey?

POLICY/POLITICS: The McLaughlin Group Library : Transcript

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You probably know The McLaughlin Group. It’s that political talk show where a panel of extreme right-wing Republicans (Buchanan & Blankley) argue with a pair of extreme right-wing Democrats (Clift & O’Donell), and they call it representing the spectrum of American politics. God knows, it probably does.

So last weekend while I was in the gym in NYC I noticed that they were having a special on health care. Filling in for the extreme right wingers were HHS Sec Leavitt and Pfizer CEO Hank McKinnell. Filling in for the right-wing Democrats were Susan Denzter, the PBS health reporter, and Jay Crosson from Kaiser Permanente. I guess they pass for liberals these days!

I spoke with Humphrey Taylor at WHCC and he told me that the Harris data shows now that 36% of the nation thinks that the health care system needs to be completely dismantled and rebuilt — and that basically no one thinks it’s going well. That number was at 40% when Clinton was elected, so we’re on our way!  But of course that point of view wasn’t going to get represented in our mainstream "liberal" media. Here’s the transcript

As you might expect, there was a fair load of pap talked. What was said on the show is italics, my comments are in between

McLaughlin–This HSA plan puts the individual in charge of health spending, not the insurance company, so the consumer becomes the buyer, and the buyer will pay attention to the price of medical services. Patients will shop. Patients will negotiate. Patients will put the economy of the market to work. Health care will suddenly become transparent.

Grace-Marie Turner sure got to him. Has he never heard of PPO contracting?

Question: How essential is the market dynamic for health cost containment and quality? Jay Crosson.

MR. CROSSON: Savings accounts are a great deal.

Someone from Kaiser said that? Can he do basic math? Isn’t his organization reeling from the problems of competing with the HDHPs? His buddy Robbie Pearl certainly thinks so.

They’re a wonderful deal for people, and they make a lot of sense. We just need to make sure that the deductible part of these plans does not interfere with patients’ access to those very services we need to prevent the complications of heart disease, hypertension and the like.

And why oh why would that be a problem for a pre-paid HMO with lots of chronically ill people? (Don’t answer, it’s rhetorical). And if it is, why are HSAs a "great deal".

Don’t worry, there’s a journalist here to talk some (and I mean only some) sense. 

MS. DENTZER: It’ll help at the margin. Most of these plans essentially are high-deductible health insurance plans. But broad coverage is going to kick in for people at $5,000 or $10,000. So if you have a serious chronic illness, you’re going to shoot through that in no time. So it’s not going to influence — if we think about the fact that 80 percent of health spending is related to 20 percent of individuals who are high-cost, very sick individuals, as Hank says, it’s not going to affect those people. It’ll help, but it reminds me of a bumper sticker I saw recently that said, "You should buckle your car seat belt because it will keep aliens from snatching you out of the car." I mean, it’s a good idea to buckle your seat belt, but it’s not going to create these enormous effects that some people claim.

But who needs sense when a pharma CEO who’s presided over his company’s stock going into the tank can rehash some real rubbish, that is coincidentally, bad news for his company!

MR. MCKINNELL: Well, an informed consumer, in a free market with choices, improves quality and reduces costs. We have many, many examples of this; two, actually, in the medical field. One is cosmetic surgery. The other is Lasik surgery, where, in the last four years, the quality has improved and the cost to the consumer has fallen by half. It does require transparency in pricing and quality, and that’s an enormous hurdle that we’re going to have to —

Let’s ignore the fact that Lasik surgery not only doesn’t represent the major problem–dealing with chronic care–but that actually the "proof" of its price decline has been shown to be bullshit by Paul Ginsberg. And that when you get to the many examples, it’s not two out of many; it’s two–Lasik and boob jobs. 

MR. MCLAUGHLIN: Well, as a matter of public policy, would you recommend to the president that he make mandatory health insurance for 45 million Americans who don’t have it, on the basis — MR. CROSSON: Yes. Not now.  I think it’s a reasonable plan, but we need to see how it works in Massachusetts. They have some big problems they have to overcome first.

Very brave Mr. Crosson. But don’t worry, if you want to hear some real ignorance ask a pharma CEO.

MR. MCKINNELL: Well, there’s two important characteristics of the Massachusetts plan. One is it was a bipartisan effort. I can’t see that happening in Washington today, unfortunately. Secondly, it is a way to solve what we call the problem of the uninsured.

<Here comes the real rubbish

But the uninsured don’t have a problem. They get access to health care. It’s a problem for all of us who pay taxes and all of us who pay medical bills.

The uninsured get access to health care? In the middle of "Cover the Uninsured Week", and with the IOM saying that 18,000 Americans die a year from being uninsured, McKinnell couldn’t think of a single qualifier to put in that sentence?

The real answer here is to provide an insurance mechanism, which they’ve done, but it also needs to be able to purchase a high-quality plan. That high-quality plan has not been defined yet.

But what he didn’t say is "if you let us write the bill like we did in 2003 we’ll make sure that the ‘high-quality health plan’ covers all our expensive drugs, and that the tax payer gets screwed".

Meanwhile he’s still speaking the mantra of "I want to be a consumer goods company":


MR. MCLAUGHLIN: If you carry your thinking to its logical conclusion,
you’re going to recommend the elimination of employer- sponsored or
underwritten health insurance for employees. Is that correct?


MR. MCKINNELL: I do think that would be a good idea, for the simple
reason that employers aren’t particularly good at providing health
benefits to their employees. We don’t provide life insurance or
automobile insurance. Why would we provide health insurance? Let’s put
that in the hands of the consumers spending their own dollars.

Given the very effective job pharma’s done running up its profits at the hands of third party payers over the years, I’m baffled as to why they think they’re going to do better given that the margins of a typical consumer goods company are way below theirs. Perhaps he thinks a 40% decline in their stock price isn’t enough…or is he just possibly saying something he doesn’t really mean. If so that habit was catching, and Leavitt was getting infected:


MR. MCLAUGHLIN: The president likes bold moves. Will you recommend to
him, Mr. Secretary, that he mandate health insurance for 45 million
Americans and the other Americans who don’t have it? LEAVITT: It’s (the Mass plan) a powerful idea, and it needs to be tried. And
if it works, other states will follow. And who knows? Maybe the United
States will.

On the other hand he forgot to say….."err, no. We don’t believe in that communistic single payer government run health care nonsense".

Then of course they went on to the real issue of health reform–or at least the one everyone can agree to agree on. More IT please. And then McKinnell actually said something sensible:


MR. MCKINNELL: Well, you won’t get any disagreement on this panel of
the need for electronic medical records. But let me caution you that it
will take a lot longer than we think.

And then we’re onto the predictions–

SEC. LEAVITT: In five years, that irritating medical clipboard they
always hand you when you walk into the clinic will be a thing of the
past.

Maybe we should be buying Phreesia stock then.

MR.
MCKINNELL: My prediction: During our lifetime, the pharmaceutical
industry will eliminate the risk of cancer and heart disease for our
children and grandchildren.

And put itself out of business! But don’t worry I’ll be long retired

MR. CROSSON: This time the health-care crisis is real. The country will
solve it. We always get to the right answer.

Gotta love an optimist. After all we’ve cracked the problems of the Middle east, energy, education, the drug war, etc, etc. What’s this little nugget compared to those!

MS. DENTZER: Medical research will lead us to universal coverage,
because people won’t stand for giving up the benefits that it will show
us in the next 15 years.

And I think she may well be right, but it’ll  be coverage that either McKinnell and the industry or the taxpayer is not going to likeMR. MCLAUGHLIN:  The Massachusetts experiment will work and it will spread.

So a show just like our health care system. Everyone screaming stuff that they heard they ought to be saying without thinking whether it benefited them. The lone journalist having to play the sensible analyst without a real industry critic being let in the room. And no discussion or thought about those who are really getting the shaft. Then again, a show just like Washington.

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