The Health Care Blog – Page 477 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

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…

What a New Benefit From Starbucks Teaches Us About the Future of Employer Provided Health Insurance

Jun 17, 2014• 12

By DAVID DRANOVE and CRAIG GARTHWAITE

Starbucks, which taught America to love lattes, made news this week with the announcement of a new tuition benefit for its partners (Starbucks-speak for employees). At first glance this move seems like simply another benefit in Starbucks relatively (for its industry) generous compensation package. In particular, Starbucks has long been heralded for providing health insurance for all partners working more than 20 hours per week. It is this connection to health insurance that we wish to explore. While Howard Schulz the founder and current CEO of Starbucks has long said the firm offers health insurance because it is the “right thing to do” for their employees, we have always suspected a more profit maximizing goal for this compensation decision. If we put on our strategy hats (we are both members of Kellogg’s Strategy Department), we can deduce that as a profit-maximizing firm, what Starbucks giveth with tuition benefits it may soon taketh away from health insurance benefits. In the process, Starbucks may be heralding the demise of employer sponsored health insurance, something we have predicted in previous blogs.

Health Care’s Rube Goldberg Machine. Who Is Responsible?

Jun 12, 2014• 31

By RICHARD GUNDERMAN, MD and Brian Callender, MD

Rube Goldberg was an American cartoonist and inventor, perhaps best known for the extremely complicated contraptions he devised for performing the simplest tasks. Each year, a national Rube Goldberg Machine Contest is held, challenging competitors to devise bizarre contrivances that can shine a shoe or zip a zipper. One day while watching a group of children marvel at such a machine in a museum, a thought occurred to one of us: As healthcare becomes more complex, the interactions between patients, physicians, hospitals, payers, and communities increasingly resemble a Rube Goldberg machine.

Consider a recent case. Ms. Jones was a 50-something year old African American woman with type I diabetes, high blood pressure and end-stage kidney disease requiring peritoneal dialysis, a form of dialysis performed nightly at home. She was recently admitted to the hospital because of an apartment fire that destroyed everything she owned, including her home dialysis equipment and medications. Once she was hospitalized, the medical team restarted her dialysis, restored her blood chemistries to normal, corrected her blood sugar, and began to make plans for her discharge. There was just one problem. They had no place to send her.

Ms. Jones could not return to her apartment, which had essentially burnt to the ground. She did not qualify for admission to a nursing home. And she couldn’t afford to rent a new apartment, at a cost of about $1,500 per month. She had paid for insurance on the apartment for years, but had recently let the insurance lapse to help finance the purchase of an $8,000 living room suite. The medical team had heard that social service agencies would provide one month’s rent, but it turned out that she could get only one-time distributions of $100 from the Red Cross and $200 from the Salvation Army – not nearly enough.

As the days rolled by, the medical team caring for Ms. Jones began feeling escalating pressure from hospital administration to discharge her. Her medical problems had been taken care of, and there was no medical need for her to remain in a hospital bed at a cost of $1,500 per day. The team arranged to get her dialysis supplies delivered to her sister’s house, hoping that she could stay there until she found a place of her own. But it turned out that too many people were already living there. Attempts to find temporary housing through friends and her church dead-ended. Hotels she contacted were all too expensive. Going to a homeless shelter was not a viable option; it would give her a place to sleep, but she couldn’t perform her dialysis there. She volunteered that she could live out of her car, for which she reportedly used some of the $300 to buy gas, but it later turned out that she did not have one.

As pressure to discharge Ms. Jones mounted, team members became increasingly frustrated. Each new hope was thwarted by an opposing reality. The team had provided their patient with the best available medical care, marshaling the impressive resources of a major academic medical center to solve her acute medical problems as effectively and efficiently as possible. But now they had run up against a barrier for which they lacked the necessary training and resources – not a medical problem so much as a social one. Treating acute illness was doable, but looking out for their patient as a whole person with a real life outside the hospital was proving quite another matter.

How Business Can Save America From Health Care

Jun 12, 2014• 3

By BRIAN KLEPPER

One of America’s most enduring mysteries is why the organizations that pay for most health care don’t work together to force better value from the health careindustry.We pay double for health care what our competitors in other developed nations do, but studies show that more than half of our annual health care spend – equal to 9% of GDP or our 2012 budget deficit – provides zero value. Every health care sector has devised mechanisms that allow it to extract much more money than it is legitimately entitled to. Health plans contract for and pass through the costs of products and services at high multiples of what any volume-based purchaser can buy them for in the market. Medical societies campaign for excessive medical service values that Medicare and commercial payers base their payments on. Hospitals routinely over-treat and have egregious unit pricing. There are scores of examples.Decades of these behaviors have made health care cost growth the most serious threat to America’s national economic security. Medicare and Medicaid cost growth remains the primary driver of federal budget deficits. Over the past decade, 79% of the growth in household income has been absorbed by health care. Health care’s relentless demand for an ever-increasing percentage of total resources compromises other critical economic needs, like education and infrastructure replenishment.Health care costs have been particularly corrosive to business competitiveness. Three-fourths of CFOs now report that health care cost is their most serious business concern. Commercial health plan premiums have grown almost five times overall inflation over the past 14 years. Businesses in international markets must overcome a 9+ percent health care cost disadvantage, just to be on a level playing field with their competitors in Australia, Korea or Germany.The health care industry’s efforts to maximize revenues have been strengthened by its lobby, which spins health policy to favor its interests. In 2009, as the Affordable Care Act was formulated, health care organizations fielded eight lobbyists for every Congressional representative, providing an unprecedented $1.2 billion in campaign contributions to Congress in exchange for influence over the shape of the law. These activities go on continuously behind the scenes and ensure that nearly every health care law and rule is structured to the industry’s advantage and at the expense of the common interest.Health care is now America’s largest and most influential industry, consuming almost one dollar in five. Only one group is more powerful, and that’s everyone else. Only if America’s non-health care business community mobilizes on this problem, becoming a counterweight to the health care industry’s influence over markets and policy, can we bring health care back to rights.

The Angry Patient: A Primer For Physicians.

Jun 12, 2014• 14

By Arshya Vahabzadeh

Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.

The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding and thinking about these categories, physicians can begin to identify the root of the anger and take measures to address it. This exercise might seem simplistic at first. However, you’ll be amazed by how powerful the results can be.

Why do patients become angry? What are the common “root” causes?

1. Pain

Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.

2. Fear and worry

Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.

3. Feeling unheard or uninvolved

Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.

Who Is Your Sugar Data?

Jun 12, 2014• 13

By JORDAN SHLAIN MD

Doctors (and patients) must own their data or they will lose the most precious asset in healthcare and possibly their future.

I hate to be the voice that repeats what others are saying, however it was recently stated in the Wall Street Journal and has been retweeted in the digital health echo-chamber: “Data is the currency of healthcare”…and it is liquid. Liquid gold. It can be packaged, repurposed and traded for big money.

It hit me right between the eyes last year at the HIMSS conference – : who were all these people, and what were they peddling? What are they making and what were they selling? Data-Gold. As a doctor on the front lines, I had a sinking feeling and the cold realization that while all the razzle-dazzle on the exhibition floor (complete with models, give-aways and million dollar booths), the data that was being traded was collected by doctors and provided by patients. Simply put, patients are data and the doctors role is to collate, codify and create meta-data. That is, doctors synthesize thedata presented and generate more data (diagnosis, treatment) which we then enter into a machine (electronic medical record). That little machine is connected to some tubes and wires and the data defies gravity and heads straight up to the cloud.

The image that continues to torture my imagination is an army doctors, running from room to room on the proverbial hamster wheel of medicine entering data up to the cloud where nymphs with gold cups of champagne and data/analytics CEO’s were bathing in hundred dollar bills chortling merrily at their successes (on the backs of the data collectors).

While the Sugar Data’s mint cash, doctors are told they can expect decreasing reimbursement for the next decade.

Encyclopedia Britannica is a cautionary tale for doctors (and patients). They had all the data but did not understand it’s value when digitized. Wikipedia ate their lunch. I had lunch the other day with a physician employed by a foundation and was flummoxed to hear that her $5,000 performance bonus check was going to the foundation, not her. She had no idea, nor any access to the performace data and had it not been for an accidental letter sent to her about the check, she would have never known. Ah, the dark art of data control. If we as a society don’t get this digital health data ownership correct, actors will be creating the health version of credit default swaps. oy.

An Outbreak of Outbreaks

Jun 11, 2014• 2

By Melinda Moore, Andrew M. Parker, and Courtney Gidengil

Lately, stories about outbreaks seem to be spreading faster than the diseases themselves. An outbreak of measles in Ohio is just part of an 18-year high of U.S. cases. Meanwhile, polio continues to circulate in Pakistan, Afghanistan, and Nigeria, while spreading to other countries, like Cameroon, Equatorial Guinea, and Syria, leading the World Health Organization to declare a “Public Health Emergency of International Concern” last month.

The Role of Globalization

As recent threats of H5N1, H1N1, and MERS attest, the increasingly global nature of infectious diseases presents serious risks. Foreign tourists, Americans returning home from international travel, immigrants, and refugees can all expose countries to disease.

With modern transportation shuttling people and products to nearly any part of the world in a matter of hours, the volume of these comings and goings is unprecedented. In 2008, approximately 360 million travelers entered the United States, which also takes in about 50,000 refugees annually.

It should be unsurprising, then, that the Ohio measles outbreak started when unvaccinated Amish missionaries visited the Philippines, then returned home. Infected persons spread the disease to others within their largely unvaccinated communities. The last naturally occurring U.S. outbreak of polio occurred in similar fashion: An outbreak in the Netherlands spread to Canada in 1978, then to the United States the following year, all among unvaccinated Amish populations across four states.

Compared to the United States, nations experiencing social unrest and political conflict face even more serious obstacles to preventing infectious disease.

Strife can interrupt routine vaccination campaigns, as is largely happening with polio. For example, the largest numbers of polio cases last year were in Somalia and Pakistan. Refugees and other displaced populations without health care access can create fertile settings for disease spread, especially if they’re not protected by vaccination. Health workers involved in vaccination campaigns can become targets of violence. And in some areas—Nigeria, for example—religious leaders haveconvinced their followers that the polio vaccine is a biological weaponpromulgated by the West.

For the most part, the United States doesn’t face these barriers. In America, vaccination is more of a choice. Unfortunately, some Americans are putting themselves, their families, and their communities at risk by choosing not to get vaccinated. If those who opt out of vaccination travel to areas where diseases are more common or come in contact with individuals arriving from such areas, they’ll be at risk of becoming ill from otherwise preventable diseases.Continue reading…

How Does the VA’s Technology Rate Against Other EMR Vendors?

Jun 10, 2014• 3

By EDMUND BILLINGS, MD

Health care for veterans has been all over the news. At the same time, the DoD is moving to procure a replacement EHR system. So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”

The case studies include a chapter comparing America’s two most broadly deployed EHRs: The VA’s VistA and Epic. The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems. As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”

VistA

VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.

In the mid 90’s, VistA became the instrument of change at the VA.

The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999. Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization …Continue reading…

Coming To a Decision On Decision-Support Technology

Jun 10, 2014• 21

By JAAN SIDOROV, MD

For more than a decade, a running joke among electronic health (EHR) record skeptics has been that its clunky “decision support” functions, defined as the on-screen provision of clinical knowledge and patient information that helps physicians enhance patient care , is condemned to always remain an innovation of the future. Yet, while published studies like this continue to fuel doubt about the prime-time readiness of this EHR-based technology, a growing body of clinical research suggests that the science is getting better. Jonathan Cohn, writing in The Atlantic, points out that IBM’s Watson has achieved enough of a level of sophistication to warrant clinical trials at prestigious institutions such as the Cleveland Clinic and Memorial Sloan-Kettering.

Unfortunately, there is an under-recognized threat to EHR-based decision support: the dysfunctional U.S. tort system.

The experience of Google’s “driverless car” may be instructive. According to National Public Radio, years of testing is putting this technology within reach of consumers. Thanks to the prospect of fewer accidents, better transportation options for the disabled, reduced traffic congestion and lower hydrocarbon consumption, some states have responded by attempting to support this promising technology with “enabling legislation.”

Unfortunately, the legislation in some state jurisdictions is being hindered by the prospect of complicated lawsuits. As physicians know all too well, when a single mishap lands in court, adroit attorneys can use the legal doctrine of joint and several liability to tap multiple deep pockets to increase the potential size of the award. In the case of driverless cars – in which the owner is more of a passenger than a driver – the accidents that are bound to happen could metastasize upstream from the owner and tie up the driverless automobile manufacturers and all of their business partners in time-consuming and expensive litigation.

Ditto the EHR’s decision support technology. Even with Watson’s intelligence, medicine will remain imperfect and allegations of medical mistakes will be inevitable. When lawsuits arise, the defendant medical providers will likely argue that their judgment was clouded by the very technology that otherwise helped them better serve their other patients. Personal injury lawyers are unlikely to let that theory of liability go unused. Tapping the same kind of lucrative joint-and-several legal theories that have served them so well in decades of standard malpractice litigation, they’ll undoubtedly be happy to name the EHR manufacturer and all of its decision-support business partners in these lawsuits.

10 Things You Can Do With CMS Data

Jun 9, 2014• 17

By Farzad Mostashari,MD

Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery.

This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job. Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times. The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of months since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.