The Health Care Blog – Page 475 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Penalizing Hospitals For Being Unsafe

Jun 23, 2014• 15

By ASHISH JHA, MD

Adverse events – when bad things happen to patients because of what we as medical professionals do – are a leading cause of suffering and death in the U.S. and globally. Indeed, as I have written before, patient safety is a major issue in American healthcare, and one that has gotten far too little attention. Tens of thousands of Americans die needlessly because of preventable infections, medication errors, surgical mishaps, and so forth. As I wrote previously, according to Office of Inspector General (OIG), when an older American walks into a hospital, he or she has about a 1 in 4 chance of suffering some sort of injury during their stay. Many of these are debilitating, life-threatening, or even fatal. Things are not much better for younger Americans.

Given the magnitude of the problem, many of us have decried the surprising lack of attention and focus on this issue from policymakers. Well, things are changing – and while some of that change is good, some of it worries me. Congress, as part of the Affordable Care Act, required Centers for Medicare and Medicaid Services (CMS) to penalize hospitals that had high rates of “HACs” – Hospital Acquired Conditions. CMS has done the best it can, putting together a combination of infections (as identified through clinical surveillance and reported to the CDC) and other complications (as identified through the Patient Safety Indicators, or PSIs). PSIs are useful – they use algorithms to identify complications coded in the billing data that hospitals send to CMS. However, there are three potential problems with PSIs: hospitals vary in how hard they look for complications, they vary in how diligently they code complications, and finally, although PSIs are risk-adjusted, their risk-adjustment is not very good — and sicker patients generally have more complications.

So, HACs are imperfect – but the bottom line is, every metric is imperfect. Are HACs particularly imperfect? Are the problems with HACs worse than with other measures? I think we have some reason to be concerned.

What Wall Street Can Teach Health Care About Targets and Measurement

Jun 23, 2014• 9

By Ben Wanamaker and Devin Bean

One thing the health care industry should admire about Wall Street capitalists is their ability to define their target and measure how well they are doing in achieving their aim. Most people would agree the aim of capitalism is profit (saying nothing of whether that is the right aim or not). The measures of that aim are reasonably straightforward using a standardized language of accounting rules. These standardized rules make it easy to compare one business to another using financial ratios (e.g., profit margin, return on capital, return on assets, etc.). When armed with knowledge of the rules and data to compute the financial ratios, deciding what to invest in becomes fairly straightforward—you invest in the opportunities that drive the highest profits over the shortest period of time.

What is the aim of health care? Many of us would say it is health. If that is the case, however, we have been rotten resource allocators. Take diabetes, for example. In 2011 there were over 60 million care events in the US related to diabetes. The cost per episode is plotted on the chart below. It clearly shows (not surprisingly) that the sicker you get, the more expensive your care is. This is not to say that we shouldn’t spend anything on very sick patients. What it does indicate is that though we say we value health, we actually choose to spend our money on sickness.

What would need to change to aim the health care system at health (vs. sickness) and effectively measure our returns on that investment? Here are a few thoughts:

1- Institute a common language for measuring health (and return on health investment)—Countries with developed capital markets almost always have a regulator that imposes a standardized language for financial measurement and reporting. In the United States this regulator is the Securities and Exchange Commission and the standardized language is Generally Accepted Accounting Principles (GAAP). Professor Regina Herzlinger of Harvard Business School has advocated for an ‘SEC’ for healthcare measurement and reporting. We join her chorus in advocating for this as a critical foundational need on which to base improvement going forward.

2- Create business models that make money on health (instead of sickness)— Patients have jobs to be done related to both health and sickness. Unfortunately, in the US providers by and large can only be paid for treating sickness, so the incentive to create businesses truly focused on health has been low. That is changing with the advent of new payment models and technologies such as telehealth, remote monitoring, and predictive analytics. We encourage entrepreneurs to ambitiously pursue business models where providers can make money on health care independent of sick care.

What’s the Value of a Cancer Cure?

Jun 21, 2014• 24

By Cyndy Nayer and Leonard Kish

When CMS approved Solvadi, Gilead’s $84,000 drug for hepatitis C, the stakes were raised in drug price wars. Two opposing forces, one, a financial push toward lower costs came up against an opposing force of public sentiment. The FDA’s goal of getting 90% of patients moved from costly branded prescriptions to generics met with an an large outcry in social and traditional media for providing the best available care, rallying around the story of a patient. The wave of sentiment seems to have won over CMS.

Granted, CMS was likely considering the reversal in its policy on Solvadi, but it was the May 12^th coverage by the Kaiser Family Foundation and NPR of the patient who was denied treatment, and the amplification across social media that turned the tide toward coverage.

Solvadi had not been approved by the patient’s prescription drug carrier, so physicians lobbied CMS for coverage of Solvadi and the life of the patient. Solvadi appears to cure liver cancer in 90% of the patients who take it as recommended. CMS agreed. As a single payer, they have the incentive to balance drug costs and benefits with other costs and benefits, and new therapies often win the fight for coverage.

Getting Covered: The decision to pay for drug combinations is often quicker than FDA approval of the drug combinations

Objective health policy observers such as KFF note that in the early days of successful antiviral drug treatment for HIV, payers allowed doctors to “mix and match” medications in “off-label” or unapproved combinations as they thought best. Medicare is often slow to approve the physician-driven cocktails, so getting CMS to adopt the strategy was a win for many very sick people in this country, as it sets a precedent for “exceptions.”

One doctor at Beth Israel Health System in Boston has a trial that has shown that combining Solvadi with another high-cost treatment, Olysio (by Janssen, cost $66,000 for a course of treatment) resulted in 90-100% cure rate.

The CMS statement in this case noted that that “the new policy will apply broadly to hepatitis C patients whose doctors prescribe the combined use of the two drugs because they meet certain criteria laid out in January by the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases.” Those guidelines recommend the combined use of the two drugs in patients with advanced liver disease who have failed to be cured by earlier drug regimens – even though the FDA has not yet approved the combination—because Medicare guidelines say a patient must have access to a therapy if his or her condition warrants it.

It’s the GPs, Stupid. Care Coordination in Britain’s NHS.

Jun 21, 2014• 13

By SAURABH JHA, MD

A recent report from the Commonwealth Fund places the US last amongst developing nations in healthcare. For self-loathing Americans, Christmas couldn’t have come earlier. Raptures of ecstasy were oozing from pores of self-satisfying righteous indignation.

Anyway that, and the shakiness of the metrics for another time.

For now I will focus on one of the conclusions. In analyzing the Britain’s high score on the management of chronic conditions the authors attributed this care coordination to the widespread adoption of health information technology.

That’s like someone saying Chinese food is tasty because chopsticks are widely used.

Sigh! Like quants so fastidious about decimal points they’ve missed the overall point.

Where do I begin?

I’ll start with Mesozoic era, i.e. before health IT was thrust upon Britain’s general practitioners (GPs). Then you had GPs and specialists. In Britain GPs are not optional ornaments for the mantelpiece that you pick up from Ikea when you feel like.

No, they are rather compulsory. Everyone needs to be registered with a GP. Ok, you don’t get fined if you don’t have one, but if you want a referral to a cardiologist you need to see your GP which means you must have one to see in the first place.

Read my lips: no GP, no cardiologist.

If your cardiologist thinks there is nothing wrong with your heart and your problems are supratentorial for which you need to see a shrink, then he must write a letter to your GP asking that he might consider referring you to the psychiatrist. The specialist can’t send you directly to another specialist, bypassing your GP.

What’s In Our Medicine Cabinets?

Jun 20, 2014• 8

By HANS DUVEFELT, MD

Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole) with over $6 billion in sales, narrowly beating out the previous few years’ winner, Nexium.

The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data.

A country’s medicine cabinets tell us something about its culture and its predominant issues.

From the late 1960’s to the early 1980’s the tranquilizer Valium (diazepam) was the top grossing drug. The 1965 US sales volume of tranquilizers was somewhere around 166 million prescriptions or 14% of all prescriptions filled in this country. Both “uppers” and “downers” were subjects of the 1966 best seller “Valley of the Dolls”. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.

So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, the latter two sometimes self-inflicted through dietary indiscretion, and now back to psychiatric conditions like schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.

One cannot help but stop and reflect on this pharmaceutical sales phenomenon.

The postwar years, although portrayed in media as a time of health care advances, optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930’s, born in the early to mid 1920’s.

Are Doctors Paid Too Much? Behind Medicine’s Nasty Little PR Problem

Jun 19, 2014• 20

By PAUL KECKLEY

On the front page of last Tuesday’s Wall Street Journal was this headline: “Taxpayers Foot Big Bills from Handful of Doctors.” It is a two-page story about a clinician whose practice drew attention from the WSJ research team that combed through the recently released Medicare Utilization and Payment database released in April. They wrote:

“Ronald S. Weaver isn’t a cardiologist. Yet 98% of the $2.3 million that the Los Angeles doctor’s practice received from Medicare in 2012 was for a cardiac procedure, according to recently released government data…The government data show that out of the thousands of cardiology providers who treated Medicare patients in 2012, just 239 billed for the procedure, and they used it on fewer than 5% of their patients. The 141 cardiologists at the Cleveland Clinic, renowned for its heart care, performed it on only 6 patients last year. Dr. Weaver’s clinic administered it to 99.5% of his Medicare patients…”

Lets face it: curiosity about what other people earn is a national pastime. Pro golfers qualify for their tournaments based on their publicly accessible official winnings. NFL agents bargain for their clients based on position-specific compensation comparables. We are frequently reminded that members of Congress “officially” earn $174,000 plus attractive perks, and of late, executive compensation for most of America’s public companies has become a major focus for Board Compensation Committee’s who are being pushed by shareholders to reign in their generous comp packages. So it’s understandable that physicians bristle at stories like this one. We would as well if in their shoes.

Here’s why the story is particularly challenging for the medical profession:

1-Physician income is high relative to what most American’s earn. Though wide-ranging across the various specialties in medical practice, the ratio of physician income to the median income in the U.S. ($51,324) is from a low of 3.6:1 for family practice to 13.9:1 for the highest earning clinicians in radiology, orthopedics and others (and that does not include their income from ownership in surgery centers, testing facilities and other services). Physicians think they deserve to be paid more than any other profession, reasoning theirs is a higher calling, their debt higher (averaging $170,000 for the 86% that borrow for medical school) and their training and expertise more valuable to society than others. Stories like this draw attention to how much physicians “might” earn and lend to suspicions that belly-aching by some in their ranks claiming they earn too little is more about greed than the greater good. Income potential is important to everyone: physicians want to earn as much as they can, and keep score against their peers and other high-earning professions. Many feel underpaid; some indeed are. But relative to what’s made in the vast majority of households, they are well paid.

How Conflict of Interest Became a Health Care Urban Legend

Jun 19, 2014• 14

By RICHARD GUNDERMAN, MD

Throughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations. The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others. The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them. Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.

Something similar may be afoot in the profession of medicine today. The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it. In fact, its proponents argue that no physician is safe. Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need. The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.

For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers. Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs. If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice. The implication? Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.

Be Prepared: Beyond the Alphabet Soup of Value-Based Care

Jun 19, 2014• 7

By JOSH SEIDMAN

ACO, MSSP, BPCI, HIE, CQM, P4P, PCMH, yadda, yadda, yadda … The litany of acronyms describing changing P&D (excuse me, payment and delivery) models can sometimes numb the senses. But it would be unwise to allow the latest healthcare jargon to lull you into an AIC—an acronym-induced coma, for which I believe there is a new ICD-10 code—because the world might look a lot different when you snap out of it.

Little debate exists that the U.S. healthcare system needs to transition from turnstile medicine to value-based care, from a predominantly fee-for-service payment model to one that emphasizes accountability for population health. This, of course, is not a novel concept, so the biggest challenges relate to how we get there. As many skeptics have argued, the same dynamics have existed before – unsustainable healthcare costs and too little value for our money – so the Talmudic question arises: Why is this era different from all other eras?

EHRs have changed the playing field completely
Reporting of comparative performance is now embedded into the delivery system
We understand the centrality of patient engagement
Today’s incentives reward greater accountability and value

There are some fundamental differences compared to, for example, the environment that existed in the 1990s when some experts believed managed care would change the underlying cost structure of the health care system. A majority of providers now have implemented electronic health records (EHRs) and an increasing number are – or soon will be as a result of Stage 2 “Meaningful Use” – able to exchange clinical data across network and vendor boundaries. The expectation that quality measurement will be used for holding providers accountable has taken root and most health care organizations regularly submit standardized performance data to public and private payers, purchasers and independent accrediting bodies. Providers increasingly recognize that their success in population health management relates to their ability to effectively engage with their patients in collaborative relationships.

Click This, Not That: Talking to Patients About Reliable Online Health Information

Jun 19, 2014• 1

By DANIELLE JONES

Most physicians agree that we have an ethical obligation to help educate our patients about what’s going on with their health, but what does that look like in a world overwhelmed with digital health information? And how do we budget appropriate time when we’re already struggling to balance shorter appointment times, more documentation requirements and busier clinic schedules?

It’s estimated that 72 percent of patients get a majority of their health information online. With an abundance of biased and incorrect information on the internet, our responsibility as physicians has evolved from simply teaching patients about their health conditions to now include educating patients on where and how to find and identify reliable health information.

This premise goes back to why I use social media. We have a responsibility to share, or at the very least be cognizant of, reliable health information in the realm where our patients seek it. In the olden days that looked like an exam room; today it looks like a Google search.

Here are four ways to efficiently help ensure patients have the resources they need to find reliable health information, despite cramped clinic visits and time constraints.

Ask: How can you possibly know where patients find their information if you don’t ask? I have patients come in with birth plans all the time and quite frequently they’ve printed them out from a website with little-to-no additional research into the (often very specific) things they’ve requested. You can’t possibly know or understand their views unless you ask.
Take 2: I understand how limited our time is. I’m a resident with a busy clinic and short, often over-booked appointment slots, but taking two minutes to discuss reliable health information with your patients has great potential for improving patient care and decreasing un-needed visits and calls.
Prep: Have pre-written, condition-specific information for your patients and include curated links to additional reliable information for those who may want it. It’s as simple as a “dot-phrase” on most major EMR systems or a copy/paste file you can quickly email or print.
Encourage: Encourage your patients to take control of their health by being informed. Encourage them to ask questions and explain things back to you, so you’re certain they have a grasp on it. Encourage them to share what they’ve learned in their searches.

Danielle Jones, MD is a a fellow of The American Resident Project, where this post first appeared. Danielle went to college at Texas A&M University (Gig ‘Em Aggies!) and completed her medical school at Texas Tech. Dr. Jones is interested in fertility medicine, social media and health technology. Currently, Dr. Jones is an Ob/Gyn resident in Texas, where she lives with her husband, twin baby girls and three crazy dogs

Launching Aledade

Jun 18, 2014• 21

By FARZAD MOSTASHARI, MD

Today, I’m launching a new company, called Aledade.

Aledade partners with independent primary care physicians to make it easy and inexpensive for them to form and join Accountable Care Organizations (ACO) in which doctors are paid to deliver the best care, not the most care.

This is good for patients who will find that their trusted primary care doctors are more available and better informed than ever before. It’s good for doctors who want to practice the best medicine possible, the way they always wanted to. It’s good for businesses and health plans looking for healthcare partners that deliver the highest possible value and outcomes. And it’s good for the country as higher quality, lower cost care will help lessen the strain on our budget and our economy.

The world of start-ups may not be the usual path for those leaving a senior federal post, but it’s the right decision.

For me, Health IT was never the “ends,” but a “means” to better health and better care, and I continue to believe that better data and technology is the key to a successful transformation of health care. And it is why the attempts to do so now can succeed, where they have failed before.

Empowering doctors on the frontlines of medicine with cutting edge technology that helps them understand and improve the health of all their patients- that is the mission of our new company, and one that has animated my entire career. Continue reading…