The Health Care Blog – Page 362 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

How Radiologists Think

May 29, 2016• 11

By SAURABH JHA, MD

flying cadeucii Diagnostic tests such as CAT scans are not perfect. A test can make two errors. It can call a diseased person healthy – a false negative. This is like acquitting a person guilty of a crime. Or a test can falsely call a healthy person diseased – a false positive. This is like convicting an innocent person of a crime that she did not commit. There is a trade-off between false negatives and false positives. To achieve fewer false negatives we incur more false positives.

Physicians do not want to be wrong. Since error is possible we must choose which side to err towards. That is we must choose between two wrongness. We have chosen to reduce false negatives at the expense of false positives. Why this is so is illustrated by screening mammography for breast cancer.

A woman who has cancer which the mammogram picks up is thankful to her physician for picking up the cancer and, plausibly, saving her life.

A woman who does not have cancer and whose mammogram is normal is also thankful to her physician. The doctor does not deserve to be thanked as she played no hand in the absence of the patient’s cancer. But instead of thanking genes or the cosmic lottery, the patient thanks the doctor.

Grading Hospital Report Cards (Again)

May 27, 2016• 3

By MICHAEL MILLENSON

flying cadeucii Medicare recently delayed a plan to issue a simple “star” rating of individual hospitals’ care after 60 senators and 225 House members signed letters supported by major industry groups that questioned Medicare’s methodology.

Rick Pollack, president and chief executive officer of the American Hospital Association (AHA), hailed the hiatus and pledged to make ratings more “useful and helpful for patients.” Perhaps. But while a summary grade for care quality has never fit hospitals—where the orthopedists could have a leg up on competitors, while the cardiac surgeons’ results are disheartening—it’s also true that hospitals have consistently fought attempts at transparency. Over an astonishing stretch of almost 100 years, they’ve done so crudely (burning the results of the first national quality survey in a hotel furnace to keep them from the press), through the courts (suing to prevent release of infection data), and using political clout.

E-mail Liberacion!

May 26, 2016• 3

By JOHN HALAMKA

John Halamka In 2011 and 2012 I wrote about the increasing problem of Business Spam – unsolicited, unconsented advertising that has grown in volume to the point that it constitutes more than half of my email . In 2016, I’ve done an experiment – I’ve not opted in to any newsletter, any website offering notifications or any vendor offering information. I’ve monitored my mailbox for violators of good email practices.

This month, we put a stop to it – cold turkey. Anyone sending business spam is now blocked from the 22,000 users of Beth Israel Deaconess and its affiliates.

Here’s how we did it – using a commercially available appliance we have black listed organizations which send bulk email and companies which violate unsolicited email policies.

A Reality Check on Workplace Wellness

May 25, 2016• 13

By JIM PURCELL

flying cadeucii In 1971, President Nixon declared a war on drugs, and decades later our country’s efforts to battle drug addiction remains largely a failure. Even here on idyllic Cape Cod, we see deaths by overdose and suicide in numbers that are horrifying, particularly with our youngsters. This epidemic shows little sign of abating as communities grapple with the scourge of runaway drug addiction and its gut-wrenching consequences.

So, it’s fair to ask: given our societal failure to stop drug abuse, should we throw in the towel because it’s, as we say here in Massachusetts, wicked hard? Is it acceptable to let drug users spiral downward with predictable ruinous consequences, because to intervene and provide programs that might help could be called invasive or ineffective? Of course not. Because we cannot and will not abandon people with serious health conditions who, on their own, cannot recover.

The workplace and its wellness are not so very different. Today’s American workforce is anything but healthy. Poor health is overwhelmingly the result of unhealthy lifestyles, and it inflicts incredible damage on employers and on employees and their families. It’s a national tragedy, and frankly, it’s a disgrace that we have not had the collective will to do more about it.

Yet, there are those who suggest that we not only give up on trying to improve unhealthy lifestyles, but also that we give up on workplace wellness altogether. I categorically disagree.

The Domino Effect of House v. Burwell

May 24, 2016• 1

By PAUL KECKLEY

Screen Shot 2016-05-24 at 11.50.02 AM

Last week, U.S. District Court of Appeals Judge Rosemary Collyer issued a ruling in House v. Burwell that could cripple the law. In her opinion, the President overstepped his Constitutional authority in granting cost sharing subsidies for those lacking insurance coverage since budgetary approval is required from Congress.

The specific constitutional question is this: Did the administration or specifically the Secretaries of Health and Human Services and Treasury violate Article I, §9, cl 7 of the U.S. Constitution when they “spent public monies that were not appropriated by the Congress.” (United States House of Representatives v. Burwell, 130 F. Supp. 3d 53, 81 D.D.C. 2015). The constitution is explicit:

No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law; and a regular Statement and Account of the Receipts and Expenditures of all public Money shall be published from time to time. (U.S. Const. art. I, § 9, cl. 7.) The courts will have to decide if the portion of the cost sharing subsidies (ACA Sections 1401, 1402) disbursed by the federal government without Congressional authorization violates the law.

Seven Principles For Better Information Technology

May 23, 2016• 6

By JAMES S. GESSNER, M.D.

Screen Shot 2016-05-23 at 5.21.53 PM Physicians well know the rapid advance of information technology in medicine over the last decade. Pushed by federal and state regulations and requirements, the adoption of electronic medical records has been swift. Today, some 90 percent of physicians in Massachusetts use some form of electronic medical records.

While health information technology (HIT) arrived with great promise and adoption has been quick, widespread acceptance has lagged, and EHRs remain a major concern among physicians of all specialties. Among the most contentious issues: interoperability, clinical workflow efficiency, and the myriad demands of reporting patient data as required by Meaningful Use and the Physician Quality Reporting System, among others.

Some physicians have embraced HIT; they see it as a way to reduce medical errors, streamline workloads, and offer a path to improved outcomes. Others view it as an impediment to the physician-patient relationship, a huge expense, a tool that consumes too much time, and a source of immense frustration. Some have even stopped practicing medicine because they found the rules and regulations and operations too onerous.

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.