The Health Care Blog – Page 479 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Socialized or Not, We Can Learn from the VA

May 29, 2014• 27

By ART KELLERMANN, MD

In a post on the New York Times’ Economix blog not long ago, Princeton economics professor Uwe E. Reinhardt addresses the common characterization of the British health care system as “socialized medicine.” The label is most often used pejoratively in the United States to suggest that if anything resembling Great Britain’s National Health System (NHS) were adopted in the U.S., it would invariably deliver low-quality health care and produce poor health outcomes.

Ironically, Reinhardt notes, the U.S. already has a close cousin to the NHS within our borders. It’s the national network of VA Hospitals, clinics and skilled nursing facilities operated by our Veterans Healthcare Administration, part of the Department of Veterans Affairs. By almost every measure, the VA is recognized as delivering consistently high-quality care to its patients.

Among the evidence Reinhardt cites is an “eye-opening” (his words) 2004 RAND study from in the Annals of Internal Medicine that examined the quality of VA care, comparing the medical records of VA patients with a national sample and evaluating how effectively health care is delivered to each group (see a summary of that study).

RAND’s study, led by Dr. Steven Asch, found that the VA system delivered higher-quality care than the national sample of private hospitals on all measures except acute care (on which the two samples performed comparably). In nearly every other respect, VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.

Vendor Management Systems and the Commoditization of Physicians and Nurses

May 29, 2014• 3

By Val Jones, MD

In a policy environment where quality measures and patient satisfaction ratings are becoming the basis for reimbursement rates, one wonders how VMS software is getting traction. Perhaps desperate times call for desperate measures, and the challenge of filling employment gaps is driving interest in impersonal digital match services? Rural hospitals are desperate to recruit quality candidates, and with a severe physician shortage looming, warm bodies are becoming an acceptable solution to staffing needs.

As distasteful as the thought of computer-matching physicians to hospitals may be, the real problems of VMS systems only become apparent with experience. After discussing user experience with several hospital system employees and reading various blogs and online debates here’s what I discovered:

1. Garbage In, Garbage Out. The people who input physician data (including their certifications, medical malpractice histories, and licensing data) have no incentive to insure accuracy of information. Head hunter agencies are paid when the physicians/nurses they enter into the database are matched to a hospital.

To make sure that their providers get first dibs, they may leave out information, misrepresent availability, and in extreme cases, even falsify certification statuses. These errors are often caught during the hospital credentialing process, which results in many hours of wasted time on the part of internal credentialing personnel, and delays in filling the position. In other cases, the errors are not caught during credentialing and legal problems ensue when impaired providers are hired accidentally.

Personal Tech

May 29, 2014• 17

By ROB LAMBERTS, MD

My 87 year-old father broke his hip this past weekend. He was in Michigan for a party for his 101 year-old sister, and fell as he tried to put away her wheelchair. The good news is that he’s otherwise pretty healthy, so he should do fine.

Still, getting old sucks.

During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: technology can really make things much easier:

I communicated with all of my siblings about what was going on and gave my “doctor’s perspective” to them via email.
I updated friends and other family members via Facebook.
I have used social media to communicate cousins about what is going to happen after he’s discharged from the hospital and coordinate our plans.

All in all, tech has really made things much easier.

This reality is in stark contrast to the recent headline I read on Medscape: “Doctors are Talking: EHRs Destroy the Patient Encounter.” The article talks about the use of scribes (a clerical person in the exam room, not a pal of the Pharisee) to compensate for the inefficiencies of the computer in the exam room. Physician reaction is predictable: most see electronic records as an intrusion of “big brother” into the exam room.

To me, the suggestion to use a scribe (increasing overhead by one FTE) to make the system profitable is ample evidence of EMR being anti-efficient.

Despite this, I continue to beat the drum for the use of technology as a positive force for health care improvement. In fact, I think that an increased use of tech is needed to truly make care better. Why do I do so, in face of the mounting frustrations of physicians with computerized records? Am I wrong, or are they?

Neither. The problem with electronic records is not with the tech itself, it is with the purpose of the medical record. Records are not for patient care or communication, they are the goods doctors give to the payors in exchange for money. They are the end-product of patient care, the product we sell. Doctors aren’t paid to give care, they are paid to document it. Electronic records simply make it so doctors can produce more documents in less time, complying with ever-increasingly complex rules for documentation.

Will Tech Revolutionize Health Care This Time?

May 28, 2014• 66

By JOE FLOWER

After decades of bravely keeping them at bay, health care is beginning to be overwhelmed by “fast, cheap, and out of control” new technologies, from BYOD (“bring your own device”) tablets in the operating room, to apps and dongles that turn your smart phone into a Star Trek Tricorder, to 3-D printed skulls. (No, not a souvenir of the Grateful Dead, a Harley decoration or a pastry for the Mexican Dia de Los Muertos, but an actual skullcap to repair someone’s head. Take measurements from a scan, set to work in a cad-cam program, press Cmd-P and boom! There you have it: new ear-to-ear skull top, ready for implant.)

Each new category, we are told, will Revolutionize Health Care, making it orders of magnitude better and far less expensive. Yet the experience of the last three decades is that each new technology only adds complexity and expense.

So what will it be? Will some of these new technologies actually transform health care? Which ones? How can we know?

There is an answer, but it does not lie in the technologies. It lies in the economics. It lies in the reason we have so much waste in health care. We have so much waste because we get paid for it.

Yes, it’s that simple. In an insurance-supported fee-for-service system, we don’t get paid to solve problems. We get paid to do stuff that might solve a problem. The more stuff we do, and the more complex the stuff we do, the more impressive the machines we use, the more we get paid.

A Tale of a Wasteful Technology

A few presidencies back, I was at a medical conference at a resort on a hilltop near San Diego. I was invited into a trailer to see a demo of a marvellous new technology — computer-aided mammography. I had never even taken a close look at a mammogram, so I was immediately impressed with how difficult it is to pick possible tumours out of the cloudy images. The computer could show you the possibilities, easy as pie, drawing little circles around each suspicious nodule.

But, I asked, will people trust a computer to do such an important job?

Oh, the computer is just helping, I was told. All the scans will be seen by a human radiologist. The computer just makes sure the radiologist does not miss any possibilities.

I thought, Hmmm, if you have a radiologist looking at every scan anyway, why bother with the computer program? Are skilled radiologists in the habit of missing a lot of possible tumors? From the sound of it, I thought what we would get is a lot of false positives, unnecessary call-backs and biopsies, and a lot of unnecessarily worried women. After all, if the computer says something might be a tumor, now the radiologist is put in the position of proving that it isn’t.

I didn’t see any reason that this technology would catch on. I didn’t see it because the reason was not in the technology, it was in the economics.

Years later, as we are trending toward standardizing on this technology across the industry, the results of various studies have shown exactly what I suspected they would: lots of false positives, call-backs and biopsies, and not one tumor that would not have been found without the computer. Not one. At an added cost trending toward half a billion dollars per year.

Do We Really Need the VA?

May 28, 2014• 16

By PAUL KECKLEY

Last Wednesday, President Obama called the much-publicized problems in the Veterans Affairs health system “disgraceful” as delays in care in at least 26 facilities grabbed media attention. In testimony before Senate and House Congressional committees, VA officials disclosed systemic misrepresentations about the timeliness of treatments in VA primary care clinics: rather than getting care within 14 days of request, many veterans appear to have waited 6-12 months to see a doctor, and some are alleged to have died while waiting.

In referencing a special report due this week that assesses the scope of the problem in the Department of Veterans Affairs, the President’s commitment to fix the problem was unequivocal: “I want to see what the results of these reports are and there is going to be accountability.”

As I have watched the VA storyline play out over the course of the past few weeks, I found myself asking questions the reporters weren’t:

Why do we need to operate a separate system of 820 clinics and 151 hospitals for Veterans?

Might the system of care for the 21 million it currently serves not be better coordinated through the U.S. health care system of 5200 public and private hospitals, 820,000 physicians, 1200 federally qualified health centers, 2000 community mental health clinics, 56,000 pharmacies and 1700 retail clinics? In most communities, there’s a surplus of beds.

In most communities, those with insurance can get doctors’ appointments and receive treatment. Veterans who lack private coverage, like those who are uninsured, have fewer choices. It is not a capacity issue: it is an economic issue.

And common sense suggests we might redeploy some the VA health administration’s $60.3B budget for better coordination with the private systems that already operate in our communities while reducing duplication of services and their associated costs.

Why don’t we get serious and fix the problem of access to primary care shortage once and for all? It’s not just a veterans’ problem. Those who live in poorer neighborhoods lack access.

The Cheeseburger Study

May 28, 2014

By VIK KHANNA & ALAN CASSELS

Two weeks ago, Vik wrote a column for the The Health Care Blog on the now infamous meat-and-cheese study done by a team of researchers led by folks from USC. You can read the column, and the hilarious comments, here. I sent the column to one of the researchers, using the messaging available at LinkedIn. Here is that researcher’s response in its entirety:

I feel no need to get into a debate with someone who doesn’t understand basic statistics, how research is conducted, and has written a statement that is blatantly wrong. It does worry me that you are propagating yourself as an “expert” when you can’t seem to critically evaluate or understand a study. I know that this study is not perfect, hardly any are, especially in epidemiology, but the points you bring up in your blog are completely misconstrued and show very poor understanding of research methodology.

If you had actually read and understood the paper you would see that we controlled for waist circumstance [sic] and BMI. Also, this isn’t some random population of fat, low educated, American smokers, it is a nationally representative sample–unfortunately this is what the American population looks like. Finally, the idea that you think our supplemental tables house the real results illustrates your lack of understanding about statistics or how mortality models are run.

That being said, if you come up with a legitimate critique, I would be happy to engage in a friendly debate. When you attack something, I would suggest you make sure you understand it first, otherwise it is hard to legitimize anything else you say. I find it ironic that most of the push back from this paper has been from the general public who don’t have experience doing these types of studies, while for the most part, the scientific community (at least from people at R1 universities) has been fairly receptive.

We are glad to offer this legitimate critique, beginning with what we find in the very first sentence of the Results discussion that is not in the paper itself, but in the supplementary materials: “Using Cox Proportional Hazard Models, we found no association between protein consumption and either all-cause, CVD, or cancer mortality (Table S2).” Table S1 makes the point even more clearly: all-cause mortality in the low protein group was 42.9%. All-cause mortality in the high protein group was 42.9%, meaning that there is ZERO impact on overall mortality from protein variation at the extremes.

Download Two of These And Call Me In the Morning

May 28, 2014• 5

By BRIAN LEVINE, MD

When it comes to discussing exercise with friends, family and patients, it seems that many of us are at a loss for words. What kind of exercise should we recommend? How much exercise is enough? How much is too much? How do I know that my patient is actually exercising? How do I prescribe exercise?

According to the U.S. Department of Health and Human Services, U.S. adults should engage in moderately intense physical activity for a minimum of 150 minutes each week; this is equivalent to 30 minutes a day, 5 days per week [1]. While it is relatively easy to keep track of the duration and frequency of exercise, it is much more difficult to quantify the intensity of an activity, let alone ensure that the activity is “moderate” for the entire 30 minutes.

In fact, in a 2008 study of women’s understanding of “moderate-intensity” of physical activity as presented in the popular media, the authors found it is not enough to simply hear and read a description of physical activity, but that it requires practice [2].

So, what are we to do? Should we have our patients log their daily activities? Should we have our patients show us sign-in sheets from the local gym?

It turns out that the dilemma of how to quantify physical activity has been a hot topic for more than 50 years. In 1965, a Japanese inventor developed the first pedometer to give people the opportunity to meet measurable goals and, thus, increase their physical activity. The device was called the Manpo-Kei (meaning “10,000 steps meter”) and it was based on research by Dr. Yoshiro Hatano that demonstrated that 10,000 steps per day allowed for a proper balance between the traditional Japanese caloric intake and the activity-based caloric expenditure of walking approximately five miles per day (the average person’s stride length is approximately 2.5 feet long, therefore 2,000 steps/mile) [3].

Tending to the Health Care Workers of America

May 27, 2014• 12

By Timothy Hoff

Given the attention now paid to implementing national health reform, the bulk of which is now upon us as 7 million new individuals now have health insurance, one important issue remains largely ignored by policy makers and industry leaders–health care workers are very unhappy.

A 2012 national survey of 24,000 physicians across all specialties found that if given the choice, just over half of these doctors — only 54 percent — would choose medicine as a career again. Fifty-nine percent of physicians in a 2013 survey could not recommend their profession to a younger person, and forty-two percent were dissatisfied in their jobs. Forty percent of physicians in another 2013 national survey self-identified as burned out.

Nursing has gained the moniker of one of the least happy jobs in America, with nurses traditionally experiencing high rates of job dissatisfaction, burnout, and turnover. Some of the reason for this malaise among our highest status health professionals has to do with the stressful, uncertain nature of health care work.

But it also is an outcome of the everyday worlds in which all health care workers now find themselves: a world drenched in paperwork, packed patient schedules, and decreased control. In short, the new world of health reform.

We are in the midst of a technological and business revolution in health care delivery. We are also on expanding patient demand in ways not seen in generations. But we are not meeting the needs of health care workers, who are expected to produce at a higher level than ever before.

If We Want Lower Health Care Spending, We Are Going to Have to Pay for It

May 26, 2014• 13

By David Dranove & Craig Garthwaite

Ultimately, spending less on health care is a relatively easy task: We either need to consume fewer services, or spend less on the services that we consume. But much like we teach our Kellogg students about maximizing profits, the devil is in the details.

It’s certainly tempting to ask the government to swoop in on a white stallion and solve the all our problems by fiat. For example, we could have the government simply exploit its monopsony power and set prices, but an artificially low price will lead to an inefficiently low quantity of services and future innovation (stay tuned, we will have more to say about this next week).

Similarly, we could explicitly ration quantities (as opposed to implicitly doing it through a large uninsured population). But how could we hope to determine the right level of care? Ultimately, if we ask the government to unilaterally fix this problem, instead of a white stallion we could behold a pale horse and all that it entails.

The good part, perhaps the best part, about the Affordable Care Act is that it attempts to address this problem using market forces. The question is whether we are ready for what these market forces will entail.

We will focus today on the role of market forces in the insurance market to control prices in the newly established ACA exchanges.

This month the Obama administration announced that it would allow insurers to use “reference pricing” for insurance programs in the exchanges. Under a reference pricing system, insurers set the maximum price they will pay for a specific set of services and if patients go to a facility that costs more than that amount they are required to pay the difference.

If Marketing Is so Dangerous, Should Medical Schools Be Doing so Much of It?

May 25, 2014• 5

By Richard Gunderman, MD

Beginning about 5 years ago, many US medical schools introduced severe restrictions on marketing activities by pharmaceutical companies and medical device manufacturers.

These measures often prohibited representatives of such firms from entering patient care areas and even medical school facilities, with the exception of tightly controlled training activities, and then by appointment only. In some cases, medical schools have issued outright bans against industry support of educational activities.

What is the rationale behind such actions? It boils down to a concern that industry funding may inappropriately influence both medical education and patient care. For example, a physician visited by an industry representative might be more likely to prescribe one of the firm’s drugs. In announcing a ban on such activities, one school likened the industry to Don Juan, worrying that physicians might prescribe drugs because they were “seduced by industry,” and not because “it’s best for the patient.”

There is evidence that even physicians who believe their decision making is not biased by marketing are in fact affected by it. Moreover, a good deal of such marketing is not exactly purely scientific. A perusal of medical journals reveals a plethora of full-page ads featuring slogans such as:

“Simplicity is clear information at your fingertips,” and highlighting images such as a physician walking down a hallway with a tiger, describing the featured drug as a “powerful partner.”

Such marketing is not inexpensive. Placing a full-page ad in a medical journal typically costs around $4,000. On the other hand, as an air traveler I have come across a number of slick full-page airline magazines ads touting medical schools and their affiliated hospitals.

These cost on average $24,000.