The Health Care Blog – Page 264 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Doctor Who Thwarted the Charge of the General Medical Council – Part 1

Aug 5, 2018• 2

By SAURABH JHA

After Dr. Hadiza Bawa-Garba was convicted for manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy who presented to Leicester Royal Infirmary with diarrhea and vomiting, she was referred to the Medical Practitioners Tribunal (MPT). The General Medical Council (GMC) is the professional regulatory body for physicians. But the MPT determines whether a physician is fit to practice. Though the tribunal is nested within the GMC and therefore within an earshot of its opinions, it is a decision-making body which is theoretically independent of the GMC.

The tribunal met in 2017, 6 years after Jack’s death, to decide whether Dr. Bawa-Garba, after the manslaughter conviction, should be allowed to practice medicine again, whether she should be suspended for a year, or her name be permanently erased (“struck off”) from the medical register. The GMC wanted Dr. Bawa-Garba to be struck off from the medical register because they felt that her care of Jack fell so short of the expected standard, that her return to practice would not only endanger patients but undermine public confidence in the medical profession. The GMC expected the MPT to agree with its uncompromising stance, and the MPT might well have, and probably would have, but for the efforts of Dr. Jonathan Cusack, a consultant neonatologist at Leicester Royal Infirmary (LRI), and a former supervisor and mentor of Dr. Bawa-Garba’s.

Cusack is unassuming even by British standards. You will not find him on social media or taking selfies. A soft-spoken northerner with a steely nerve and an uncompromising deference to facts, Cusack is both old-school and new-school. He has that unassailable integrity which is immeasurable but instantly recognizable. But he’s also savvy – and understands the British medical, regulatory and legal systems inside out. If Dr. Bawa-Garba’s license is reinstated, Cusack’s role would be akin to that of the code breakers in the Second World War. Dr. Bawa-Garba trusts him implicitly. Her legal team can’t function without him.

Cusack was loyally involved in both the rehabilitation of Dr. Bawa-Garba’s clinical confidence after Jack’s death, and her trial. I met him after the first day’s appeal hearing in the pub opposite the Courts of Justice. Originally hesitant to speak to me, being the ostentatious expat Brit that I am, he agreed to an interview on the condition that I not make too much of a song and dance about his contribution. I promised that I wouldn’t. I lied.

Can We Teach a New Dog Old Tricks? A Conversation with Gary Klein

Aug 5, 2018

By SAURABH JHA

There is a rage against expertise these days. Data is all rage. What is the value of experience and judgment when we have abundant information, guidelines, and protocols? Can’t we just have a protocol for every situation? Are doctors overly concerned about making errors? I discuss these issues with Gary Klein, a renowned cognitive scientist and author of Streetlights and Shadows.

Listen to our discussion on Radiology Firing Line.

About the Author:

Saurabh Jha is a radiologist and contributing editor on THCB. He hosts Radiology Firing Line podcasts. He can be reached on Twitter @RogueRad

Health Care’s Third Wave

Aug 3, 2018• 10

By DAVID M. CORDANI

Change and American health care have become synonymous. “Change” can be exciting and life-altering when it refers to the innovative new therapies and treatments that improve or extend life, many of those originating in the United States. Change, though, can be a tremendous source of anxiety for families concerned with the affordability of care and stability in their health care coverage choices. It is the tension between these two definitions of change that the United States has struggled to solve over the past three decades.

As we have all witnessed, the health care marketplace has gone through two successive waves of change over the past 30 years, with the third wave now upon us. The first wave was managed care, which sought to rein in cost and quality relative to “unmanaged care.” But while managed care made some gains, it still proved to be unsustainable in its constraint of choice and its focus on financing “sick care” rather than on optimization of health.

The second wave of “reforms” saw companies like Cigna evolve – or change – from “insurance” to a health services focus, with more engagement and support for the individual and partnerships with health care providers and pharmaceutical manufacturers predicated on the health outcomes achieved rather than the volume of services provided. The second wave has seen the health care industry as a whole work together to improve health, lower health risks and improve the cost structure of the employer-sponsored market, which has in turn subsidized the entire system.

In that environment, Cigna has been able to deliver the best medical cost trend over the past five years – below 3 percent in 2017 or half that of the industry. So why risk disrupting a winning formula by acquiring the pharmacy services company Express Scripts? Because the system still isn’t sustainable and maintaining the status quo of rising costs means you are effectively moving backwards.

A Libertarian’s Case Against Free Markets in Health Care

Aug 2, 2018• 27

By ROMAN ZAMISHKA

In the final act of Shakespeare’s Richard III, the eponymous villain king arrives on the battlefield to fight against Richmond, who will soon become Henry VII. During the battle, Richard is dismounted as his horse is killed and in a mad frenzy wades through the battlefield screaming “A horse, a horse! My kingdom for a horse!” Richard shows us how market value can change drastically depending on the circumstances, or your mental state, and even the most absurd exchange rate can become reasonable in a moment of crisis.

This presumably arbitrary nature of prices should be the first thing about the US healthcare market that catches the attention of any student of economics. Prices for the same procedure vary greatly between hospitals on opposite sides of the street and even then appear to have no basis in reality. Further investigation reveals many other features of the healthcare market that economics teaches us will increase transaction costs and the misallocation of resources. The prices we discussed are generally not paid by the patient, but by a third party insurer. Often the patient isn’t even able to select the insurer but is assigned one by his or her employer. What the patient thinks of the insurer’s ability as a steward of his or her premiums is irrelevant. Further, contracts between providers or pharmacies and the insurer completely hide the true price from the patient’s view. In addition, anti-competitive certificate of need laws limit competition between providers and expensive regulations compel providers to merge to compete in a nuclear arms race with the insurers, although the real victim is the patient’s wallet over which the providers and insurers fight their proxy wars. The best way to explain the US healthcare system is if you took every economic best practice and then did the opposite. How does one get out of this mess?

A Doctor Thanks His Mentor – Steve Jobs

Aug 1, 2018

By DAVIS LIU, MD

I’ve been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden. Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life. Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn’t have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs. Lest you think I’m a devoted Apple fan, I never bought anything from Apple until the spring of 2010. Their products though beautifully designed were always too expensive. I’m just a little too frugal. I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes. Yet, the value proposition was never compelling enough until the release of the first generation iPad. Then the iPhone 4. Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn’t about the amazing magical products that have changed my life as well as millions of others. It’s more than that. What he has mentored me on is vision, perspective, persistence, and leadership.

Shielding My Daughter’s Heart

Aug 1, 2018

By LYGEIA RICCIARDI

A couple of years ago, I gave birth to a baby girl, Ada. She looked perfect, but the doctors told me she had a significant heart murmur. When I held her in my arms at night I could hear blood rushing through a hole in her heart that shouldn’t have been there.

My husband and I took Ada to a pediatric cardiologist, who said she would probably need surgery to close that hole. For an entire year of tests and hospital visits, we lived in fear that open heart surgery was just around the corner. And then one day it was. “It’s time,” the cardiologist declared, “That hole is dangerously impeding her growth.”

Was Open-Heart Surgery Necessary?

I am grateful to live in a time and place in which surgery—even surgery on a heart the size of a golf ball—is an option. This kind of procedure has undoubtedly saved many lives. But it’s not without risks. More than 100,000 people die in this country every year from preventable medical errors. And hospital infections are a serious problem, too. We didn’t like the idea of subjecting a life so new, so tenuous, to a procedure of such magnitude unless there was a clear case for it. I’m not going to sugar coat this: We were talking about sawing open my baby’s ribs and stopping her heart and lungs.

How Much Are We Paying For a Choice of Insurers?

Aug 1, 2018

By Patricia Salber, MD

A number of years ago, a family doc friend of mine took me on a tour of his small group practice. He proudly showed me the exam rooms, his medical equipment, and other parts of the facility that related to patient care. Then we came to a large room with a bunch of desks piled high with paper. He explained, bitterly, that this part of his office was for the people he had to keep on the payroll to do nothing but deal with insurers. This administrative expense was cutting his margins to the bone and did not help him take better care of his patients. He eventually left practice, to pursue a second career as a physician executive – a job that was, for him, more remunerative and more satisfying.

Part of the problem is that physicians in the US have to deal with multiple health plans – each with its own set of managed care rules, formularies (or list of approved drugs), requirements for prior authorization, rules for billing, submission of claims, and adjudication. Until recently, almost all of this administrative work was done by phone or fax. Picture this: rooms full of practice-based nurses talking to insurance company nurses about the details of a case that may or may not lead to payment for medical care.

Physician, Feed Thyself …

Aug 1, 2018

By Margaret Polaneczky, MD

This post first appeared on The Blog That Ate Manhattan.

All this medical food blogging has gotten me to thinking about the similarities between chefs and doctors.

What is the same

1. They’ve got the whites and the chef’s hat, we’ve got the greens and the caps and masks.

2. Both require intensive training with a clear hierarchy of ascent.

3. The chef and the surgeon are captains of their respective ships – the kitchen and the OR.

4. Skill with sharp instruments is necessary for both professions.

5. We both work long hours, including nights and weekends.

6. If we both do our jobs right, our clients walk out feeling better than when they walk in.

7. We have JCAHO, they have Frank Bruni.

8. A knowledge of organic and biochemistry is essential in both cooking and medicine.

The Evolving Role and Stature of Health Information Management (HIM)

Aug 1, 2018

By SETH KNELLER

Several companies with roots in the Health Information Management (HIM) sector have emerged in recent years to address the gaps and limitations associated with most EHR deployments. Although some of these companies have been around for years, and are sometimes incorrectly “boxed” as providing commoditized services in the areas of transcription and release of information services, several have developed exceptional new technology in the fields of clinical language comprehension and analytics that is highly relevant for the business objectives of the most progressive health systems.

The unique ability of certain firms to impact the evolution of the clinical documentation and analytics landscape stems from:

The much broader scope of data they can access and analyze due to their ability to source and organize both structured and unstructured clinical data.
Their position at the middle of the RCM value chain where clinical data capture and analysis intercept with complex regulatory and financial concepts that are designed to align reimbursement with the appropriateness of care being delivered.
Their potential to rationalize “siloed” functions in health systems related to case management, care coordination, utilization review, and compliance at a time when providers are responding to new reimbursement and risk-shift models that require them to operate more like payers.

Aug 1, 2018

By RACHEL KATZ

Healthcare’s Silicon Valley problem: can startups really work with healthcare organizations?

Startups and healthcare organizations: fundamental foes or perfect partners?

When opposites attract: how startups and healthcare organizations can improve care together

Silicon Valley wants to love healthcare. The industry is enormous and full of inefficiency, which is to say, perfect for technology investment. So it comes as no surprise that venture money in healthcare technology startups has quadrupled since 2011 to $4.5BN in 2015. Moreover, the government wants to invite Silicon Valley-style innovation in healthcare. In January, CMS leaders stated that the next wave of EHR policy will focus on promoting startup innovation in healthcare by incentivizing open APIs and interoperability. Everyone agrees—so let’s just get going, right?

Here’s an important truth to recognize on the eve of what some like to call the “disruption of healthcare”: Silicon Valley and healthcare are fundamentally at odds. In technology we fail fast, launch and iterate, proudly make mistakes and learn from them. In medicine, the first principle is “do no harm.” Entrepreneurs are obsessed with growth–exponential growth, hypergrowth, 10X growth–and the faster the better. Conversely, in healthcare organizations, progress is measured in months and years. My company is currently in Y Combinator, a three-month accelerator program. I have had phone calls with healthcare organizations that took longer than that to schedule.

The philosophies and operations of the two world are at odds in many ways. Too many well-intentioned startups have come up against these tensions and lost steam.

Despite this, healthcare organizations and startups can make perfect partners. I believe more startups should try to serve healthcare organizations, and more healthcare decision-makers should choose to work with startups. Here are some lesser-discussed advantages for both sides.