Above the Fold

TECHNOLOGY: The state of play at America’s leading health systems

More musings from the Healthtech meeting. Given that this is a somewhat private meeting, and I’m an invited guest, I’m not going to name names, but suffice it to say that the health systems here include many of the largest (predominantly non-profit) regional hospital systems in the US.

So from my non-scientific surveillance, where are they and what are the challenges they are facing? In general the last few years have been about automating their laboratory, pharmacy and PACS (radiology) systems. At least in some hospitals, this has led to reducing costs in testing , and getting results back much faster (in 6 minutes in one case). This of course promotes quicker decisions which filters into lower ALOS and increases ROI. The rest of the effort in the last few years has been about creating the wired and wireless infrastructure that’s needed to support the next stage of their plans–in fact wireless is a major focus.

The new challenge is CPOE and bedside medication records. Now they are starting at varying rates to move to clinical documentation at the bedside and also at the nurses station. CPOE (i.e. getting the physician ordering, particularly medication ordering, in the loop) is the major push many of the systems are working on now. This somewhat tracks with various studies showing that CPOE use is pretty low (of course it’s existed at some hospitals such as Brigham & Womens and Intermountain for several years).

Some of these systems are creating big time process improvements (so long as the medical team is bought into the decision process). But by no means do the medical staff appear to be so compliant in all cases–in one case there was no improvement in several basic process measures. So putting the system in is only part of the battle, and the medical culture still seems to be the biggest hurdle.

One big system (which has introduced a lot of new technologies) is very rigorous about incubating a test-lab learning environment before any new technology is moved into different facilities. This is part of an extremely detailed planning process, which needs exceedingly high levels of buy-in from clinical and operational staff, and rigorous assessment at all levels of every roll out. In other words there’s no organic growth of IT use, its all carefully designed. Nor are new or innovative, but untried, technologies allowed into the system. Instead the IT group makes sure that any devices or applications they introduce does not distract them from their total focus with keeping the network up for Five Nines reliability (99.999% up time). So their priority is keeping the mission critical network up. Their system hasn’t gone done unscheduled in 2 years. Some time ago Paul Saffo at IFTF said that eventually computer downtime (like phone downtime) would start killing people. Plenty of these hospital CIOs seem to believe it. So as IT becomes more integral to other parts of the hospital (ie. lab/pharmacy first, nursing next, then physicians) many hospital systems are looking for incredibly (and justifiably) high levels of network/application uptime and reliability.

And don’t mistake that putting this all in is anything other than damn hard work. The words Six Sigma and Process Improvement were heard alot. All in all they are probably not having as much fun as we technology futurists have looking at all the new toys. But in terms of creating the environment for process-driven hospital-based care, at least some of the leading systems in America are making progress.

TECHNOLOGY/QUALITY: The Digital Delivery System

Yesterday I was at Healthtech’s conference on The Digital Delivery System. Healthtech is a non-profit research consulting group which conducts research on information and medical technologies, and how their emergence and use will impact hospital systems. Healthtech is led by health care superstar Molly Coye, who’s been in both the public and private sector, and is one of the authors of the recent IOM reports on patient safety and quality. The meeting attendees are IT folk from large hospitals systems that care about how they’re going to use technology to change their clinical processes, while not being shot by their medical and financial staff in the process.

The key issue being discussed at the conference is how do you get standardized clinical procedures used uniformly across a system. IT clearly helps and is a driver, but non-IT solutions work too. The keynote speech was by Brent James, from Intermountain Healthcare (IHC) in Utah, who have long been EMR pioneers. Most of the rest of this is my take on James’ speech. Of course apologies are mine if I misconstrued information, but there was much good stuff in it. James introduced his talk with three quick stories.

a) a color coded discharge tool for severity assessment at Primary Childrens hospital was developed by the residents and was taken up by the management. During a viral outbreak that happens every so often in Utah, they had been so swamped that they had to close the OR for 18 days. When the next outbreak hit, using the discharge tool they were able to reduce ALOS by one day and the OR was only shut for 1 day.

b) Traditionally a general internist plus 2 assistants can manage 600 patients on Coumadin/Warfarin. With a virtual lab seeing the results of patient measurements taken across the Intermountain system, one 50% time Nurse Practitioner plus one assistant can now monitor and look after 1400 patients.

c) James’ dad enters info on an IHC website that monitors his CHF, and monitors his care every day. If any of his measures go downhill, a nurse calls and schedules follow up. He is doing well and is healthier than he’s been for a long time.

James introduced the story of how well medical care has done in improving life and health. Then James got into the nitty gritty of how poorly we’ve done to move that scientific marvel over the context of all care provided to a population. He displayed some grimly amusing charts that showed that Beta blockers were used on discharge for acute MI patients 48% of the time by major teaching hospitals (and only in the 30% range for community hospitals). And this had direct results on mortality 2 years later–mortality was higher in the community hospitals. But more to the point, as he said: "We get it right 50-55% of the time and we achieve miracles. What would happen if we got it right 70% of the time?".

Medicine is much more complex now than it used to be. Back in the 19th century there were 6 active medications; by 1970 60-100 medications. Now as a general internist you should know 600 drugs.

So can you make this complexity better? Traditionally medical practice says you can’t– the mistakes and missing the best care protocols are just the price you pay for complexity. But IHC showed that with a simple check sheet on discharge that the nurse fills out, IHC got beta blocker use from 56% up to the high 90%s! So it is possible to do better than the 55% appropriate care that RAND showed we currently expect! In the IHC system this saved 331 lives per year for CHF and reduced hospitalization rate by 551 admissions. Brent believes that closing that gap represents the future of medicine. But he didn’t want to talk about who gets the money!

Another area IHC has used IT is in avoiding ADEs (medication errors). "Voluntary" incidence reporting reveals less than 1% of actual ADEs. At IHC ADEs went from 15 per year in the 1980s (detected by incidence reporting) to 580 in 1991 (when they started counting using an IT system) but came down to 280 by 1999. At IHC they found that 66% of these ADEs were preventable–hence the reduction. And all this saves money, on average $2,400 per ADE. James thinks their error rate is still too high. But nonetheless he says if you are sick, you should come to IHC in Utah because you are going to have significantly lower chance of getting a complication!

Diabetes care is another area of concentration. (IHC is in top decile for HbA1c control in HEDIS/NCQA). Every quarter their docs get a report card on diabetic care, and IHC gives them a notification of any patient off the protocol–before the patient comes in. This can also work off the EMR, and any time a diabetic comes in a new chart front is printed out with a whole worksheet so that the patient is checked in their visit for all that’s needed according to the protocols. This measurement system is backed up with a home glucometer and an interactive website for the patient. IHC has seen care rates again improve to make them better than the top decile.

Overall the IHC experience, which has been well known within the medical quality and EBM circles needs to still get more publicity. As another speaker said later in the day, no other industry would get away with this level of safety violations. But perhaps if consumers really knew not only that appropriate care was provided just 55% of the time, but there is a real live American example of a place getting it right more than 90% of the time, the reaction would force the system into much faster change.

More on my sense of where the IT folk are on creating the infrastructure for that change tomorrow.

HEALTH PLANS: Wellpoint pay-out word is out, and the PR is not good, with UPDATE

So as a consequence of the Wellpoint/Anthem merger some two hundred plus top execs are going to get payouts that total between $150m and $350m, depending on whether or not they are kept on for three years by the new company. As you may have guessed this money won’t necessarily be shared out evenly. Len Schaeffer, the outgoing Wellpoint CEO (and former HCFA head in the 1970s) is likely to get a package of $76m, not of course counting the $184m in stock and options he’s already got.

Now the cynics among you might be thinking that ex-Wellpoint exec Ron Williams who went over to Aetna a while back and got a nice payout, should have stayed in southern California. But the real issue is that the California legislature, influenced heavily by the CMA and the Foundation for Taxpayer and Consumer Rights, is not happy! California legislators need to approve the deal, and that won’t happen with this kind of publicity.

UPDATE: California insurance commisioner John Garamendi hinted pretty strongly at yesterday’s hearings that he won’t approve the deal. It’s hard to believe that the whole thing will be scuppered, especially as there aren’t any real anti-trust issues in local markets because the two companies don’t really compete at present. But maybe Len will have to toss some of his pay-off back into the pot to make nice with the state.

POLICY/SYSTEM: Costs increases slowing slightly

The Center for Health System Change is out with its assessment of cost increases for 2003. And believe it or not, they say costs increases are slowing, down to a mere 7.9% from 9.5% in 2002 and 10% in 2001. This is worrying news for the health care system which is having trouble making its price increases stick with the rest of society slowly improving news for the economy which is being suffocated by increasing health care costs, which result in more un and under-insured individuals and more trouble for government and employers in these cash-strapped times.

HOSPITALS/POLICY: For-profits cost more, but that’s not the point!

In a publication that (hat-tip to Jacob at Family Medicine Notes who is also to be congratulated on the excellent upgrade to Medlogs) comes from the Journal of the Canadian Medical Association a meta-analysis confirms that in the US for-profit hospitals charge about 20% more than non-profits. This is not new news by any means. In fact I remembered reading almost exactly the same thing when I first learnt about the US hospital sector back in 1990. What the Canadians have done is to do a really thorough evaluation of every and any study of the topic, and it basically confirms my (often faulty) memory. Unsurprisingly Steffie and David go almost apoplectic about this in an accompanying opinion piece.

    “Investor-owned hospitals charge outrageous prices for inferior care.” said Dr. Steffie Woolhandler. “That’s not just an opinion, it’s now a proven fact. The for-profits skimp on nurses, but spend lavishly on their executives and paper-pushers.” Previous research by Drs. Woolhandler and Himmelstetin, based on financial filings by virtually all U.S. hospitals, found that administration accounted for 24.5% of total costs at non-profit hospitals vs. 34% at for-profits, while payroll costs for clinical personnel were 7 percentage points higher at non-profits.

    Dr. Woolhandler also noted that: “Previous studies have shown a consistent pattern – investor-ownership compromises care and raises costs. For-profit dialysis clinics have higher death rates. For-profit nursing homes deliver lower quality care. For profit hospices give dying patients less care. For-profit rehab facilities cost Medicare more. And for profit HMOs deliver poor quality care and have extraordinarily high overhead costs.”

Indeed their article quotes many very well known instances of for-profit companies caught with their hand well inside the cookie jar, usually that belonging to Medicare, and yes Messrs Scott, Barbakow and Scrushy know who they’re referring to! But what I’m going to say now probably will stun many of my readers who still think I’m an unreconstructed Lenninst, even though I voted for Maggie Thatcher twice in the 1980s:–I don’t believe that it’s the for-profit nature of the hospitals that’s the problem.

While it’s impossible to judge from the Canadian meta-analysis, I don’t think that these studies are necessarily apples to apples comparisons. Now get ready for some gross THCB oversimplifications here, but follow my line of reasoning. In the US there are basically three types of hospitals: a) big academic teaching hospitals, which often are in the inner cities but have a strong reputation for excellence and receive massive cross-subsidies from Medicare; b) smaller inner-city or rural hospitals that cater to a poorer population; and c) suburban hospitals that have a wealthier population. In crass terms, the first group muddles along financially cross-subsidizing from a variety of funding sources, the second group lives in the financial toilet (and is the venue for most hospital closures) while the third group tends to do very nicely thank-you. Almost all for-profit hospitals are in that group (of course) but that doesn’t mean that they are necessarily much worse offenders in terms of how much they charge, how much they upcode Medicare DRGs, and how little they give away in charity care/or fail to recover bad debts than their non-profit neighbors. Non-profit hospitals in the suburbs tend to act very like their for-profit equivalents and have tended historically to be fairly profitable. It’s not entirely a joke that Ian Morrison called one of his clients “The Sisters of Sustainable Competitive Advantage”.

I stand to be corrected on this but my guess is that if you directly compare for-profit hospitals with non-profit hospitals of the same ilk, rather than a random selection of all non-profits, you’ll most likely see that the for-profits charge slightly more and give slightly less charity care, but not by the huge amounts suggested in this study. So in other words, there’s not too much wrong with for-profit hospitals per se. Yes they tend to be in chains that centralize decisions and centralize profits, and yes more often than not they get involved in dubious practices like upcoding and paying their CEOs way too much. The problem with that line of argument is that many of the same things happen on a lesser scale in many other hospitals. And as the vast majority of hospitals are independent or are in very small non-profit systems, if you multiply up the minor “infractions” at each one, you might end up with a total in dollars that rivals the big nauseates we see in the newspapers from a Columbia or a Tenet.

Now, I do believe that these infractions are indeed a problem. So who do I blame? Most of the problem lies with the incentive system that we put hospitals under. And that system (as I’ve been saying since my very first ever post on THCB) is mostly controlled by the graduated fee-per-episode system that Medicare uses to reward hospital care. A very similar system also incents physicians and other providers to do as much as they can (and in some cases to commit outright fraud). Whether they are officially for-profit or not, everyone in the system likes extra income, and if you set up a payment system that incents more activity at a higher price and has no corresponding checks or balances, then you are going to get higher costs. This could be fixed by changing the way Medicare pays providers (and its HMO intermediaries). Potentially the very baby steps CMS is taking down the Pay for Performance path might help in that direction. But focusing on purely the role of the for-profits is like blaming the guy who owns the bar for making a profit off his patron being an alcoholic.

BLOGNOTES: Jeanne Scott’s website coming to life, and Bloglet

The wonderful Jeanne Scott of TheJeanneScottLetter is getting her newsletters back up. The most recent two are up on her site and she promises that the rest will follow. So go read! And subscribe if you haven’t already by emailing her.

On an unrelated Blognote, I finally went back through my archives of "drafts" (of which there were over one hundred remnants of things I wanted to comment on that I’d saved but never gotten to) and I’ll be trying to knock some out over the coming days. Of course it would help if current healthcare events stopped too!

Finally, I (hope that) the bloglet email service down on the right of your screen is now working with an accurate daily teaser of what’s in THCB. I tried to email those of you who have subscribed to that (free shareware) service about it the other day, but as I got zero responses either the email didn’t work, your spam filters kept me out, or I’m just not worth replying to! Please tell me it’s not the latter!

INTERNATIONAL: Tight elections and the Canada/US comparison

Up north they are having an election in the land where they no longer ever win the Stanley Cup, (although it should be noted that like the “Swiss” who won the Americas Cup over the New Zealanders mostly because the Swiss had a Kiwi crew, most “American” hockey teams are stuffed with Canucks). And the election is going to be very close. Go to this chart and follow the polls along from 2000 to today — interesting stuff and a potted history of Canadian politics in the last 4 years.

So what does this have to do with health care in the US. Well you’ve guessed it, the old chestnut of health care systems comparisons has reared its ugly head in THCB. As I mentioned a couple of weeks back, the Canadians are not planning on moving to an American system. That includes the newly resurgent Conservatives. Even if they win (and its about even in the polls now) both they and the governing Liberals are promising more cash for the current system, rather than changing course. In fact at the bottom of this news story in which (Liberal PM) Martin is trying damn hard to paint the Conservatives a shade of Republican–with references to gays and abortion–the health care issue is made clear:

    Harper (Conservative Leader, BTW) said on Friday he would inject C$10.4 billion ($7.7 billion) to C$15.2 billion into the ailing health-care system over the next five years. He pledged C$600 million to $800 million to cover drug costs over C$5,000 a year, and C$2 billion to C$3 billion a year for general health costs.

    On Thursday, Martin pledged C$26 billion to C$28 billion in new spending — including plans for a national day-care program and an expanded military — which he said could be done without driving the federal budget into the red. He too has pledged to inject more money into the public health-care system.

So basically they are outdoing each other for who will spend more on health care. And don’t forget that the Liberal government under Chretien in the 1990s actually cut healthcare costs and reduced healthcare as a share of GDP–not something that Americans have ever seen happen here!

So given that the Canadians are not heading our way, why bring this up? Well funnily enough a new report from both Federal Governments is out comparing the two countries’ health care systems. And what were the findings? Well no surprises. Insured Americans had a slightly better time in the system than all Canadians, while uninsured Americans had a worse experience. Cost was a big issue for Americans, while not one for Canadians, while waiting times were an issue for a large minority of Canucks.

    Americans were more likely to report that the quality of their health care services in general was excellent compared with Canadians (42 percent compared to 39 percent.) Among uninsured American respondents, 28 percent said the quality of the health care services they received was “excellent,” 44 percent “good,” and 28 percent “fair” or “poor.” When asked about their satisfaction with health care services in general, 53 percent of Americans and 44 percent of Canadians said they were “very satisfied,” while 37 percent of Americans and 43 percent of Canadians said they were “somewhat satisfied.” Among uninsured Americans, 39 percent were “very satisfied” with the services they received, and 40 percent were “somewhat satisfied.”

    Unmet medical needs during the past 12 months were reported by 13 percent of Americans and 11 percent of Canadians. Among those with an unmet need, Americans were more likely to identify cost as the primary barrier to health care (53 percent of unmet needs cases), while Canadians cited waiting for care as the primary barrier (32 percent of cases). Among the 11 percent of American respondents who were uninsured, four out of every ten reported an unmet medical need. Likewise, only 43 percent of the uninsured respondents said they had a regular medical doctor, compared with 80 percent of total American respondents and 85 percent of Canadian respondents.

So the message is fairly clear. With 40% of the uninsured with an unmet medical need, and less than half having access to a regular doctor, if you’re going to be uninsured in the US, move up north! Alternatively, maybe you should vote down here?

QUALITY: More evidence on the scantity of EBM

In this post, a little more from last week’s IFTF meeting. The variation in practice of evidence-based medicine was described in a speech by Bern Shen, as one of the major "impediments" to health and healthcare. THCB readers, MedRants readers and all health policy wonks (via Wennberg’s work at Dartmouth) have long known about this problem. A typical example was in the Journal of the ACC (here’s the abstract) last week, showing that heart patients usually don’t receive appropriate post-discharge drug therapy:

    Dr. Javed Butler from Vanderbilt University in Nashville, Tennessee and colleagues assessed ACEI (ace inhibitor) use among 960 hospitalized heart failure patients. They discovered that 55 percent of the patients were discharged with an ACEI order. By postdischarge day thirty, 77 percent had filled their ACEI prescription, but by one year only 63 percent were still taking the medication. "Although we expected the rate of long-term use to go down over time, we were surprised at the magnitude to which it did," Butler said in a statement.

    Moreover, if patients are not prescribed an ACEI at discharge, the chance of initiating one in the outpatient setting is "very unlikely," Butler told Reuters Health. For patients with no discharge order for ACEIs, only about 12 percent had been prescribed one by 30 days. By one year, only 19 percent of were current ACEI users.

Of course, as I’ve blogged about before, the solution is not that simple. It’s very hard for physicians to practice the "right" way all the time and even harder for them to communicate this to their patients. It requires education of physicians and patients, and the installation of sophisticated tracking information technology. None of these three are particularly in evidence in the US, although as I’ll describe in a post later this week, the Brits are marching down this path, at least for primary care.

At the meeting Dr. Catharina Maulbecker Armstrong described a service she’d been involved in running in Switzerland, where high end executives were advised about what their course of treatment should be based on the latest protocols. The service consulted with the patients’ doctors about their clients’ treatment course, but soon found that the doctors were calling them asking advice about treatment protocols for other patients. As she put it, the doctors otherwise were relying on their 20 year old memory of their medical school professors’ 20 year old memory of what to do! OK, so that’s a little over-simplified, but it does reflect the underlying the problem–physicians are taught to be independent actors relying on their memory, working on one area of the body. Moving to a medical education system based on doctors leading a team (which includes the patient), using information systems to apply the latest medical knowledge and viewing the care of the patient holistically is a non-trivial challenge.

However, Michael Millenson,author of Demanding Medical Excellence and the quality bete noir of many doctors, was also at the meeting. Although he had some uncharacteristically charitable words for some hospital folks who were making the effort to improve quality across the board (in the pursuit of reduction of medical errors), he was a little scornful of their pleas for grant funding to help them do it. As he pointed out, the folks in the room from GM and other big manufacturers probably didn’t rely on Foundation grants to improve their quality–it’s part of what the market demands. It’s the interference with that "market" demand by the medical profession that has radicalized Millenson. (I’ll be reporting on his upcoming speech to a bunch of doctors at the end of the month, or maybe I’ll be carrying back his body to his family!)

PHARMA: The New York Times opinion on GSK and Spitzer

I’ve refrained from getting too much into the Spitzer versus Glaxo legal shenanigans over Paxil, and whether results were withheld deliberately or not. However, suffice it to say that yet again Pharma’s PR is not exactly going to be helping the Republicans in an election year when you see editorial pieces like this from The New York Times.