The Health Care Blog – Page 369 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Case for Case-Based Reasoning

Mar 30, 2016• 1

By FRANK MEISSNER, MD

flying cadeucii Case-based reasoning has been formalized for purposes of computer reasoning as a four-step process^[1]:

Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.

Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.

Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.

Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

Torture the Data Until it Confesses

Mar 29, 2016• 9

By TOM EMERICK

flying cadeucii Did you ever hear the old joke where the boss says floggings will continue until morale improves? Torturing the data until results improve…or the data confesses…is not uncommon. Which is a pity.

In my career I’ve worked with companies with over 100k covered lives the claim costs of which could swing widely, from year to year, all because of a few extra transplants, big neonatal ICU cases, ventricular assist cases, etc.

Here are just a few of the huge single case claims I’ve observed in recent years:

$3.5M cancer case
$6M neonatal intensive care
$8M hemophilia case
$1.4M organ transplant
$1M ventricular assist device

This is not a complaint. After all this is what health insurance should be about, huge unbudgetable health events.

All plans have one organ transplant every 10k life years or so, most of which will cost about $1M over 6 years. A plan with 1k covered lives will have such an expense on the average of every 10 years. Of course the company may have none for 15 years and two in the 16th year. The same goes for $500k+ ventricular assist device surgeries.

Milestones or Millstones?

Mar 28, 2016• 1

By RICHARD GUNDERMAN, MD and DAREL HEITKAMP, MD

Gunderman Good intentions do not necessarily lead to good results. A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education. In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.

The goals behind the milestones initiative are laudable. Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes. They would foster self-directed learning and assessment and provide more helpful feedback. In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.

In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties. Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin. In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.

Seven Pillars of Trumpcare

Mar 26, 2016• 18

By SAURABH JHA, MD

flying cadeucii It is possible that in a few months from now, only Nate Silver’s prediction models will stand between Donald Trump and the White House. I will leave it to future anthropologists to write about the significance of that moment. For now, the question “What will President Trump be doing when he is not building a wall?” has assumed salience.

This is relatively easy to answer when it comes to health policy. Just ask what people want. Seniors don’t want Medicare rescinded. Even the free market fundamentalist group, the Tea Party, wants Medicare benefits as they stand. At one of their demonstrations against Obamacare a protester warned, without leaving a trace of irony, “Government, hands off my Medicare.”

Rest assured, Trump will protect Medicare. Even raising the eligibility age for Medicare may be off the cards as far as he is concerned. He has promised that no one will be left dying on the streets. That people no longer die on the streets, but in hospitals, because emergency rooms must treat patients regardless of their ability to pay, is irrelevant. The point is that Mr. Trump knows that the public values their healthcare. Trumpcare will show that Trump cares.

Patient-Centered Service

Mar 26, 2016• 13

By ROB LAMBERTS, MD

flying cadeucii American healthcare has a customer service problem. No, customer service in the US is terrible when it comes to healthcare. No, the customer service in the US healthcare system is horrendous. No, healthcare has the worst customer service of any industry in the US.

There. That seems about right.

What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice:

“You are the first doctor who has listened to me.”
“This office makes me feel comfortable.”
“I didn’t have to wait!”
“Where’s all the paperwork?”
“Your office staff is so helpful. They really care about my needs.”
“This is the first time I’ve been happy to come to the doctor.”
“It’s amazing to have a doctor who cares about how much things cost.”
“You explain things to me.”
“You actually return my calls.”

HillaryCare 2.0 – Back to the Future

Mar 25, 2016• 4

By JIM PURCELL

Screen Shot 2016-03-25 at 11.35.49 AM

It was 1993, nearly a generation ago. President Bill Clinton had delegated massively to the First Lady the task of putting meat on the bones of his ambitious healthcare announcement. Ms. Clinton, in turn, undertook the task of drafting and then selling to Congress what was titled the “Health Security Act of 1993,” but what is remembered as “Hillarycare.”

No one doubts Ms. Clinton’s intelligence and determination. That she was so completely derailed and the way it happened is nothing short of remarkable. In many ways, we were then so ready for reform. Many things were aligned, including a newly robust economy that lasted for over 7 years.

There are many reasons why Hillarycare failed back then, not the least of which were the AHIP sponsored television ads, Harry and Louise, who became famous for their very effective skewering of what was loosely represented to be the effects of the Act. The entire debacle became a cautionary tale about how healthcare IS different and is extremely resistant to change.

The Transparency Trap

Mar 25, 2016• 7

By NIR J HARISH, MD

flying cadeucii On a recent shift in the Emergency Department, a resident boasted to me that she had convinced a patient to have an MRI done after discharge, rather than in the hospital. She was proud of this achievement because MRIs cost much more in the hospital than they do elsewhere – sometimes thousands of dollars more. To advocates of “cost-conscious care,” a new movement in medical education that aims to instill in young doctors a sense of responsibility for the financial consequences of their decisions, this story seems to belong in the ‘win’ column.

But this story also raises troubling questions: Why wasn’t the resident more concerned about how the hospital’s charging practices were leading her to delay care for her patient? What about the prolonged anxiety the patient would suffer? What about the extra day of work she would have to miss? And most importantly, why does an MRI cost thousands of dollars more in the hospital than it does across the street?

Like many doctors, she had fallen into the ‘transparency trap.’ This phenomenon is an unintended consequence of price transparency efforts that have come in response to patients and doctors being kept in the dark for decades about the prices of common services. Unfortunately, as the CEO of one large hospital put it, “the vast majority of [prices] have no relation to anything, and certainly not to cost.” In fact, studies have shown that in a functional market, MRIs would cost somewhere around $250, and we wouldn’t be nearly as concerned about doing too many of them.

The Unaffordable Affordable Care Act Turns 6

Mar 23, 2016• 24

By DEVON M HERRICK

This week marks the sixth anniversary of the Patient Protection and Affordable Care Act (ACA). But it’s hardly anything to celebrate. The ACA was intended to make health coverage affordable using an age-old strategy referred to as OPM (other peoples’ money). For instance, ACA regulations require insurers to accept all applicants — including unprofitable ones — at rates not adjusted for their health risk. Premiums can vary somewhat based on age, but not health status. A plethora of new taxes (mostly on medical care and health insurance) are supposed to somehow make coverage more affordable. Other funding mechanisms include draconian cuts to Medicare and higher deficits to expand Medicaid.

The Narrowing of the Network

Mar 23, 2016• 7

By JIM PURCELL

The concept of restrictive (oh let’s call them euphemistically “narrowed”) networks has for decades been the third rail of healthcare. Ask Hillary Clinton, who put her foot on that third rail in the 1990’s while attempting to reform healthcare. In the same vein, HMOs in the 90’s also tried to restrict networks, resulting in vicious backlashes.

One of those backlashes was the enactment in many states of so-called “any willing provider” or “freedom of choice” legislation. At last look, some 27 states still have a form of such legislation on their books. Most credible studies show that such laws increase the cost of healthcare.

Moreover, the ability of insurers to remove physicians from their network in many states is severely restricted by so called “fair hearing” legislation that makes the pain of achieving physician expulsion worse than the pain of leaving under performing physicians in network.

We understand that when a physician cries “foul” against an insurer, public sentiment will favor the physician, and over the years, it certainly has been reflected in this and other legislative attempts to tie insurers’ hands. After all, no one wants to go to the prom with a health insurer.

As a result of this and other phenomina, there has been the highly chronicled swoop toward mediocrity in the delivery of healthcare in the United States. And insurers have certainly contributed here. Up to now, insurers have paid physicians using the fee for service payment method. This method merely requires physicians to demonstrate that they performed a function, at which point they are paid at an amount that does not vary regardless of quality or outcome. This is a completely volume driven environment with predictable results.