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Annals of Decision-Making

May 23, 2016• 19

By MICHEL ACCAD, MD

flying cadeucii A Vox.com piece about decision-making caught my attention this morning.

The story was compelling. A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain. A first neurosurgeon would not operate and recommended radiation therapy instead. The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken. The second surgeon surgeon was undeniably right. The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good? Not so, according to Vox. That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why? Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off. Variability in judgment, as always, is the enemy.

Post-Palooza News: RWJF Challenge Update

May 23, 2016

By KATHERINE HEMPSTED

Screen Shot 2016-05-23 at 7.56.39 AM At Health Datapalooza, we heard plenty about the importance of addressing the myriad information needs health care consumers have – when choosing plans and providers, receiving care, or trying to become more engaged in their own health. Therefore it seems fitting to follow the ‘palooza with an update on this year’s RWJF challenge program and introduce the next for 2017.

Although we know that consumers have many unmet information needs in the healthcare setting, our apps challenge program, which is administered by Health 2.0, has consciously focused on supporting decisions around plan choice. Our first two challenges focused on some critically important tools: cost calculators and provider directories. Use of both types have soared during the third open enrollment period, and the tools of our winner, finalists, and many others have become widely used. Some have even been linked to state exchanges or healthcare.gov.

How Big Is Too Big?

May 20, 2016• 13

By MARC-DAVID MUNK, MD

Screen Shot 2016-05-20 at 8.38.33 AM With healthcare mergers now announced seemingly every week, I’ve been giving some thought to scale: How big can/ should health systems be?

Anecdotally, I’m struck that the most impressive healthcare companies in America are super- regional players: Geissinger, Cleveland Clinic, UPMC, etc. They seem to get a lot more attention than the national players with hundreds of facilities.

Leaving aside questions like strategy (e.g. is integration of payers/doctors/hospitals the key to these successes), I’ve wondered whether regional systems are simply the right size to thrive. My suspicion is that even clever organizational structure (a topic which I wrote about last year) can’t overcome barriers that prevent large healthcare companies from innovating and thriving, particularly as companies move to risk and the business of healthcare becomes more complex. Like cellular organisms, large companies can outgrow their life support. (Interestingly, it’s actually the ratio of body volume to surface area [gas exchange, digestion, etc] that served as a constraint to organism size…)

I recently ran across a superb paper- a doctoral thesis written by Staffan Canback. Canback (who now leads the Economist Intelligence/ Canback predictive analytics consulting firm in Boston) wrote his thesis, called Limits of Firm Size: An Inquiry into Diseconomies of Scale in 2000, while a student in London. Canback argues, convincingly, that companies do become more efficient with scale, but reach a point where “diseconomies” begin to mitigate performance. This may seem intuitive: (as Canback notes, if efficiency only improved with scale then we would buy everything from one company that produces everything with great levels of efficiency). We don’t.

Beyond CQI: How Patient-Centered Care and Efficiency Go Hand-in-Hand

May 20, 2016• 2

By KRISTIE HUFF

Screen Shot 2016-06-13 at 11.29.59 AM Hospital administrators are finding that true continuous quality improvement (CQI) requires a radical change in thinking.

For decades, automakers, the packaging industry and the airline industry have created better products, improved processes and greatly increased user satisfaction by adopting the principles of CQI—which, simply put, means constantly looking at our processes and asking ourselves, “Can we do it better”?

CQI principles have been applied to the delivery of healthcare with great success. Hospitals have created and employed myriad mechanisms for all staff members/personnel to continually improve existing processes. But hospital leaders and administrators know that even after decades of dutifully applying the principles of CQI to improving delivery of care, the patient’s journey from admission to discharge is still all too often filled with missed opportunities for a speedier journey through the system and better care overall.

Administrators at leading hospitals are finding that, in some cases, CQI means adopting an entirely new model of delivery. They are also finding that the most efficient way to deliver care is also the most patient-friendly. Let me explain.

The Positive Impact of New Wage Protections on Home Health Agency Bottom Lines

May 19, 2016

By JEFFREY GROSSMAN

Screen Shot 2016-05-20 at 9.31.00 AM

In January 2016, the Department of Labor (DOL) officially extended federal wage protections to home care workers under the Fair Labor Standards Act, entitling them to the federal minimum wage, time-and-a-half pay for overtime, and pay for time spent traveling between clients. Predictably, lobbyist groups working on behalf of home care agencies have petitioned the Supreme Court to upend the new regulation. Their petition currently sits in limbo while the eight-member Court delays its’ consideration (presumably in fear of an unproductive 4-4 voting split while awaiting the confirmation of a ninth Justice). In the interim, those hoping for a review should consider the positive impacts of the new regulation and the opportunities it presents.

While on the surface this unfunded government mandate hurts home health agencies struggling to offer care within already slim Medicaid reimbursement margins, there is also a business case for increasing wages. First, increased wages will help entice new workers to the field, enabling agencies to care for more patients. Presently the median hourly wage for home care workers is $9.38[1], compared to the median for refuse collectors at $15.52 and parking enforcement workers at $16.99. While caregivers are often driven by a passion for their work, relatively low wages force many to look elsewhere. With higher pay, agencies should see an immediate impact on their ability to recruit new employees and increase revenue through improved bandwidth.

An Independent Medical Review Panel for the Candidates

May 19, 2016• 3

By ART CAPLAN and JONATHAN MORENO

Screen Shot 2016-05-19 at 9.10.32 AM As unusual as the 2016 presidential election has been, one obvious aspect has gone largely unnoticed: By the time the next president of the United States is inaugurated on Jan. 20, 2017, he or she will have reached or come close to reaching 70 years old.

That all the remaining major candidates are among the “young old” at this stage of the election process is unprecedented. Yet, in spite of the stakes for the American people, there is no independent source that can provide an adequate accounting of the medical condition of the next president.

Historians have examined the ways that previous administrations have been affected by the medical problems of presidents including Abraham Lincoln, William Henry Harrison, Woodrow Wilson, Franklin Roosevelt, John Kennedy, Lyndon Johnson and Ronald Reagan. The news has not always been positive.

The Second to Last Mile

May 18, 2016• 5

By AKASH RANDHAR and JAAN SIDOROV, MD

flying cadeucii Thanks to the ubiquity of cable, fiber and wireless internet, the “last mile” telecommunications gap that has long separated the consumer from the wide world web is finally being bridged. According to Pew Research, 84% of Americans now regularly use the internet, and 68% use smartphones to access increasingly available broadband services.

The impact on healthcare has been considerable. More than half of all Americans have already uploaded their vital signs, benchmarked their fitness levels, co-managed their medications, communicated with their providers or researched health-related information. No wonder the “mHealth” market could grow to $60 billion by the end of the decade.

Yet, as more and more patients have rushed into this growing ecosystem of apps, wearables, home devices and other gadgets, a considerable body of research suggests that U.S. health care providers are not keeping up. The poor second-to-last mile fit between consumers’ personal health technology and the providers’ incumbent information systems is turning out to be an important barrier to fully realizing the full potential of mHealth.

How should mHealth leaders respond?

Everyone agrees that healthcare technology is beset by unfriendly interfaces, poor clinical fit and opaque “black-box” programming logic. In addition to this, physicians are also well aware of the perils of inbox data overload.

Resolving these technical challenges is well within reach. Yet, healthcare leaders who are sponsoring mHealth initiatives should also consider three lessons that address the very human dimensions of connecting the second-to-last mile:

Why Medicine?

May 18, 2016• 2

By SAURABH JHA, MD

flying cadeucii Cross posted with Quartz.

When I was applying to med school some 20 years ago in the UK, I was advised not to say at the interview: “I want to be a doctor because I want to help people.”

The answer was considered too dull back then. And in any case, I was asked “Why medicine?” only once.

“I’m not sure, but it’s not because my parents forced me.” I hesitatingly answered.

The interview panel giggled at my honesty, and for breaking a stereotype about Indians. I was accepted. But I doubt that this answer would cut it today.

Showing a sense of altruism is practically mandatory today for would-be doctors – one wonders if functional MRI will soon be used to prove empathy. But when I was 17 (the age when we typically applied to study medicine) that wasn’t the case. My curriculum vitae had little evidence that I wanted to help people.

The Quality of Virtual Visits

May 17, 2016• 3

By JOE KVEDAR, MD

Joseph Kvedar Virtual visits are increasingly the rage amongst forward-thinking healthcare providers that want to jump on the telehealth band wagon. Extending the office visit across distance, using the same technology we use to keep in touch with loved ones (videoconferencing such as Skype and FaceTime), is a safe and logical way for providers to venture into a new tech-enabled world that may still be scary for some.

One way to think of this trend is to consider virtual visits an extension of the brick and mortar care model made famous a decade ago by companies like Minute Clinic. Offer convenient access to a care provider for a limited number of conditions.

Virtual visits can take place by either video or voice connection. These interactions are most often for indications that are non-life threatening, acute problems such as sore throat, ear ache, urinary tract infection and the like. There is also a role for this technology in follow up care for conditions such as diabetes and hypertension, but for this post we’ll focus on acute care.

Slavitt’s “Data Paradox”

May 16, 2016• 6

By KIP SULLIVAN

flying cadeucii Andy Slavitt began his statement at the Datapalooza conference with encouraging words for those of us who believe that the measurement craze has been a disaster and that MACRA will make it worse.

Slavitt claimed to be in favor of electronic medical record “reform” that “works with doctors, not against them.” He seemed to say he understood MACRA could aggravate the damage that “meaningful use” and the pay-for-performance fad have already inflicted on doctors.

He even accurately summarized the lousy results to date of the measurement craze. He said doctors feel all the data entry “took time away from patients and provided nothing or little back in return.” “[P]hysicians are baffled by what feels like the ‘physician data paradox,’” he said. “They are overloaded on data entry and yet rampantly under-informed.”