The Health Care Blog – Page 388 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Dismal Science Behind Financial Incentives For Docs

Jan 12, 2016• 4

By JAAN SIDOROV, MD

flying cadeucii “It is written: Man shall not live by bread alone.”
Luke 4:4

No matter what you think of the source of that quote, the idea that there may be limits to “aligning incentives” has some merit. In healthcare settings, physicians seem to be supportive of being fairly compensated for their work, but also seem to be quite skeptical about the use of “carrot and stick” style economic rewards to influence clinical practice.

Case in point is this interesting paper describing the results of a randomized clinical trial that used blood cholesterol-level control to assess the relative merits of a) rewarding just the patients vs. b) rewarding just the doctors vs. c) rewarding both patients and doctors vs. d) usual practice, or a control group.

The study took place in three marquee institutions, involving 340 primary care physicians who were already taking care of 1503 adult patients with 1) elevated cholesterol levels who 2) either had coronary artery disease or were at high risk for coronary artery disease.

About half of the patients were already on cholesterol-lowering pills.

The purpose of the study was to determine if real money could be used to increase the rate and level of prescribing a statin drug aimed at achieving levels of cholesterol control that were consistent with national guidelines.

What Do We Know About Medical Errors Associated With Electronic Medical Records?

Jan 11, 2016• 6

By ROSS KOPPEL

Recently, the Journal of Patient Safety published a powerful and important article on the role of EHRs in patient harm, errors and malpractice claims. The article is open access. Electronic Health Record–Related Events in Medical Malpractice Claims by Mark L. Graber, Dana Siegal, Heather Riah, Doug Johnston, and Kathy Kenyon.   The article is remarkable for several reasons:

Considerably over 80% of the reported errors involve horrific patient harm: many deaths, strokes, missed and significantly delayed cancer diagnoses, massive hemorrhage, 10-fold overdoses, ignored or lost critical lab results, etc.

Central to this article’ contribution is its data source and an understanding of the direction of causation of the findings: These errors came to light not because a healthcare provider noted an EHR-related problem, but because the patient was harmed, the provider was sued and there was an insurance payment. Continue reading…

Posts on EHRs, Data and Patient Safety

Jan 11, 2016

A Health IT Developer’s Confession: How Bad Software Is Made and What to Do About It by Margalit Gur-Arie

Two HIT Developers Respond: Why We’re Still Optimists About Technology’s Potential by Andy Oram and Shahid Shah
In Defense of Mistakes by Martin Samuels, MD
An Error about Mistakes By Paul Levy

How Should Errors In the Patient Medical Record Be Addressed? By Peter Elias, MD

The Year of the Hacker by JK Wall

The Quest For Zero Infections: A Fool’s Mission? by Anish Koka, MD

Uberizing Health, Data is the Vehicle … And a Right by Leonard Kish
The Last Checklist by Anna Reisman

Treating Chest Pain With a Cup of Tea

Jan 9, 2016• 6

By ANISH KOKA, MD

It is very early. I am running to the ‘clinical decision unit’ (CDU) to see a patient of mine sent in the night before from a local skilled nursing facility. Also known as clinical observation units, ‘obs’ units, or short stay observation units, these units were designed to help decompress busy emergency rooms and divert unnecessary, expensive inpatient admissions. The units are typically adjacent to emergency departments, and usually are run by emergency physicians.

My particular patient was admitted due to an episode of chest pain at her facility. A brief conversation the prior night with the emergency room staff revealed chest pain that clinically was not typical for any of the feared diagnoses of a heart attack, pulmonary embolism or an aortic dissection. An electrocardiogram and cardiac enzymes were also initially unremarkable. Regardless, the patient was elderly and had multiple other comorbidities, and was somewhat confused. I recommended a short stay to allow anything malignant to declare itself.

And so, here I was, at the observation unit, digging through pages upon pages of printed gibberish that clearly had achieved the nirvana stage of meaningful use (for those wondering, that’s after stage 3). Ironically, the most useful piece of information lay in a handwritten progress note describing the episode. I could see why the patient had been brought here to be further evaluated, but after 18 hours of negative biomarkers, electrocardiograms, and no recurrence of symptoms, I felt comfortable letting her go back to where she came from. I told the ER staff… who cancelled her stress test. A stress test? Yes, a stress test had been ordered prophylactically. We practice in a climate where every bad outcome has the potential for litigation – malpractice lawyers would have a field day with the case of anyone going to the ER, being discharged without some type of cardiac imaging study, and having a heart attack. My recommendation to discharge the patient shifts the liability of an adverse outcome from the ER squarely on to my shoulders, and thus, poof goes the stress test.

Help Us Build a Hospital In the Cloud

Jan 8, 2016

By JONATHAN BUSH

Since 2011, over $13 billion in venture funding has flooded into digital health. 2015 alone saw well over 200 digital health companies raise more than $2 million each. From personal DNA tests to on-demand doctor’s visits, startups are taking a page from technology giants (Google, Apple, Amazon) and digital unicorns (Uber, Slack) to bring health care into the internet age.

The consumerization of health care is en fuego(!), and rightfully so. With the rise of high-deductible plans, we as patients have been forced to take on greater financial responsibility for our own health. Adding fuel to the flame, the widespread adoption of internet and mobile tech has evolved patients from passive recipients of care into active managers of care. Health care’s consumerization wildfire is thrilling, and it’s created a perfect breeding ground not only for new models of care delivery to take root, but for entrepreneurs to introduce new tools and apps for the patient and provider alike.

Good Reads

Jan 8, 2016

Very Bad Numbers by Anish Koka, MD
What Would a Health Care Mutual Look Like? by Munk, MD
A Health IT Developer’s Confession: How Bad Software Is Made and What to Do About It by Margalit Gur-Arie
Think Again: Health Insurers Have No Reason To Reduce the Price of Health Care by JK Wall
This Visit May Be Recorded by Alan Schwartz and Saul Weiner
Saving Normal by Saurabh Jha, MD
The Right Not to Know by Benjamin Berkman

Would Patients Pay For This?

Jan 8, 2016

By HANS DUVEFELT, MD

Health care in America is fracturing right down the middle, and doctors are going to have to figure out if or how long they can straddle the divide between what patients want and what the Government and Corporate America want them to have.

Up until this point, the momentum has been with the payers, Medicare and the insurance industry. But the more heavy-handed they become, the more inevitable the public backlash is becoming.

It will come down to this, a kind of “straight face test” for health care: Would patients pay for this?

The Annual Wellness visit, better named “Medicare’s Non-Physical” and some forms of “Population Management” are examples. Both are great ideas; an annual health review and planning session as well as doctors maintaining an overview of, and reaching out to, high risk groups of patients – in theory neither would be anything to argue with.

The War on Death

Jan 7, 2016• 12

By SAURABH JHA, MD

Thomas Hobbes described life as pitifully “nasty, brutish, and short.” Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, brutish, and long.

Surgeon and writer, Atul Gawande, explores the medicalization of ageing and death in Being Mortal. Gawande points to a glaring deficiency in medical education. Taught to save lives and fight death, doctors don’t bow out gracefully and say enough is enough. We’re not taught about dying. We’re taught about not dying.

In our lexicon, life is a constant war against the Grim Reaper. We say inactivity kills; screening saves lives; an intervention reduces mortality by 5 %—an arithmetic impossibility as mortality for our species, barring select prophets, remains 100%. Words have precise meanings. Words also hide precise desires. It’s not that we can’t distinguish between a murderer and colorectal cancer; but by giving cancer moral agency—we wage war on cancer—we imply that death is an anomaly that must be fought.

And we fight. We fight death in the hospices. We fight death in the hospitals. In many parts of the world, more people die in hospitals than in their homes. Some die, attached to a noradrenaline infusion, in the CAT scan—the last pit stop of hope between the intensive care unit (ICU) and the morgue.

2016 Obamacare Outlook

Jan 7, 2016• 5

By ROBERT LASZEWSKI

One of the more Obamacare fluent reporters just emailed me a set of questions regarding the 2016 outlook for Obamacare.

I thought I would share my responses with you:

According to early CMS data, 38% of exchange enrollees are under age 35. Is the risk pool beginning to stabilize?

It’s too soon to know if the pool is beginning to stabilize. First, the administration’s announcement that 38% of the pool is below age 35 is disingenuous. They are counting all of the children that show up on the rolls with their families. They did not give us the far more important age 18-to-35 number.

Second, the overall subsidy eligible exchange penetration stood at about 35% at the end of 2015. Ideally, Obamacare needs to about double its penetration of the eligible to assure a balanced pool of the sick and the healthy.

Then of course, we always see these big enrollment numbers being announced by the administration only to see the block shrink dramatically by year-end.

So, it will really be a year before all of the dust settles on the 2016 enrollment and we really know what the claim levels are relative to the premiums being charged.

If rates increase too much in 2017, will those young people jump ship?

I worry more about the really poor take-up rates for the healthy people who have not signed up in the 200% of federal poverty level and above brackets than I worry about the percentage of the young who have signed up. Way too much emphasis is put on this age 18-to-35 statistic. Yes, they are more often healthy but under Obamacare the youngest pay one-third the premium of the oldest. We really need the healthy to sign up in much bigger numbers, that have so far been holding out, more than we need the young.

Like Uber for Health Care With Sherpas?

Jan 6, 2016• 12

By ROB LAMBERTS

2015 was a hard year for my father. He’s a remarkably healthy 89 year-old, with no diabetes, no hypertension, and (most importantly) he’s got a sharper mind than I do on most days. Perhaps that’s a low bar to cross, but it’s pretty good for him. I think this is from all the crossword puzzles he’s done over the years.

Dad’s troubles started around the middle of the year when he started having low back pain. This pain progressed from mild pain to being so severe that he required a wheelchair to get around the house. This is the man who, a year after breaking a hip, was impossible to keep off of a stepladder to fix something on his roof. It was a big change. After trials of conservative treatment, he was eventually diagnosed with a compression fracture of his lumbar spine (presumably from steroids he took for an inflammatory problem).

Given the severity of his pain, he ended up going to a back specialist to get a procedure to fix the compression fractures and, presumably, reduce his pain. Unfortunately, his pain increased and changed after the procedure. It got so bad, in fact, that he ended up being hospitalized in November for pain control.

The hospitalization was confusing for both him and me. It wasn’t clear if his pain was from a problem in his back, as it had moved to his leg. Yet while in the hospital he didn’t get any radiological study to determine the source. Plus, he’s quite resistant to the effects of narcotic pain medications. I really don’t like to intervene on behalf of family members unless it’s absolutely necessary, but I finally ended up talking to the hospitalist who was quite nice, but not much help. Dad was being discharged to rehab the next day and I still wasn’t clear on what was wrong after a week in the hospital.