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Above the Fold

A Closer Look at Public Trust in Healthcare

May 22, 2014• 2

By PAUL KECKLEY

Public trust matters. It’s hard to build and easy to lose.

Of late, subpar performance has drawn public attention to a wide variety of industry notables:

General Motors agreed to a fine for malfunctions resulting in 24 recalls in recent years including 2.6M most recently with faulty ignition switches.
Security breaches in customer information at Target, Michaels and other retailers hurt sales and cost at least one CEO his job.
The Department of Veterans’ Affairs has been exposed to questions about its safety record, notably delays in treating veterans in its hospitals in 9 states.

Entire industries have seen their public trust erode as a result of misdeeds or self-inflicted wounds—the investment banking industry’s mortgage loan debacle, venerable news organizations from lack of objectivity, industrial food manufacturers from unhealthy supply chain management and so on. And industries like higher education and others face tough questions about their value proposition, as if decades of good will no longer matter.

In most cases, leaders of the most prominent organizations in these industries accept responsibility, appoint task forces to investigate and address their issues with the media and investors head-on. Their trade groups, likewise, announce new initiatives to restore public confidence. They hire professionals to bolster their influence. and in some cases, rebuild their reputation.

Public trust in industries matters as much as confidence in the individual companies and organizations themselves. An industry’s reputation and good will is always buoyed by the reputation of the companies that are its marque market leaders, and always at risk as a result of the misdeeds of any member, known or unknown.

By and large, excepting occasional drug manufacturing scares or recent well-publicized safety issues in a few of the 3000U.S. compounding pharmacies, our industry has remained virtually unscathed from the ever-more-skeptical public’s thirst for muckraking. The U.S. health system enjoys the confidence of the majority, especially older adults for whom it is always top of mind.

But the reality is this: the US health industry is susceptible to erosion of its public trust, not as a result of the Affordable Care Act nor political in fighting in Congress.

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

May 22, 2014• 38

By JAAN SIDOROV, MD

As your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital. Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.

Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command. If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing. Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain. A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.

“Good grief!” says your correspondent. Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

Because Cancer.

May 21, 2014

By “Knot Telling”

Do not tell me how to feel!

For those who may not read through to the end, here is the take home: you do not get to tell me how to feel or what my attitude should be, no matter who you are.

Sure, it’s more comfortable for me and the people around me when I’m have a positive attitude, but that does not mean that I have to live “all bliss all the time” like some insane American cable television station. Being positive does not mean pretending that nothing is wrong because… cancer, people!

A young woman who, I think, just turned twenty-two posted this on her Facebook page: “That’s the thing about pain. It demands to be felt.” She knows what she is talking about, by the way.

It does no good to pretend that emotional pain does not exist. It does no good to pretend that it’s not there. The only way I’ve ever found to get through pain is to recognize it, sit with it, walk through it to the other side. Sometimes that process leaks out into the environment and then I don’t smile prettily at everyone around me. Sometimes I’m snotty and bitchy and generally not one of Jesus’ little sunbeams. Sorry about that, but… cancer, people!

Here’s another news flash. A positive, determined attitude will not cure cancer, no matter what the popular media tell you. The following quotations are from the American Cancer Society:

In 2010, the largest and best-designed scientific study to date was published. It looked at nearly 60,000 people, who were followed over time for a minimum of 30 years. This careful study controlled for smoking, alcohol use, and other known cancer risk factors. The study showed no link between personality and overall cancer risk. There was also no link between personality traits and cancer survival.

[…]

Continue reading…

Scope of Practice: Playing at the Top of My License?

May 20, 2014• 25

By Karen S. Sibert, MD

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

Early ACA Data Shows No Wave of Sick Patients

May 19, 2014• 29

By JOSH GRAY & IYUE SUNG

Since launching ACAView, our joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth, in early April, open enrollment under the Affordable Care Act (ACA) has closed for 2014 and The White House has issued final numbers: eight million people enrolled through the marketplace and five million outside the marketplace. Add another three million enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the total number of people enrolled under the ACA’s individual mandate is close to 16 million.

Since some of these enrollees had previous forms of insurance coverage, it is important to estimate overall reductions in the number of uninsured. RAND estimates that 9.3 million more Americans have insurance in Q1 of 2014, compared to Q3 of 2013, but these figures exclude the surge of enrollments in the last half of March. The Congressional Budget Office (CBO) estimates 12 million net newly insured people through either the marketplace or Medicaid (including 1 million who lost insurance), but these estimates exclude enrollments outside the marketplace.

In short, “newly insured” and “enrollment numbers” are counted in different ways and can be confusing. But let’s conservatively assume that the number of net new insured individuals is roughly nine million, or 2.8% of the population. Are these new beneficiaries having a measurable impact on medical practices?Continue reading…

Developing Physician Culture in New Risk Models

May 18, 2014• 4

By Craig Tanio, MD

There is a saying that “culture eats strategy for lunch.” Never has this been truer than when looking at primary care or physician group delivery system innovation. Health care industry leaders must invest more time creating and scaling the right culture as they innovate.

There has been a great deal of controversy on the ability of the Primary Care Medical Home (PCMH) to impact total medical costs. Critics have noted that PCMH is adding additional costs to the structure without systematically demonstrating improvement in total costs and quality.

A great deal of time has been spent debating the proper structures, processes and financial incentives that are necessary to create value in physician-led-risk or shared-savings models. However, I suspect the real issue is that culture is a major driver of performance, and it has not been systematically measured or managed.

At ChenMed, we have developed a primary-care-led model focused on the care of seniors with multiple and chronic health conditions. Funded through full-risk arrangements with Medicare Advantage plans, we outlined an overview of the original Miami-based model in Health Affairs last year [1].

Over the last three years, we have scaled the model from five centers in Miami to 36 centers in eight markets in the Southeast and Midwest. This has required us to adjust our model in ways that allow it to readily scale. We have been able to make the fundamental economics work while rapidly scaling the medical practice, and are actively working on innovations to improve value every day.

One of the foundations of our strategy is getting the physician culture right. This is not easy to measure from a health services and policy research perspective.Yet, it matters a great deal from a practical and business perspective. McKinsey and Company has developed an influence model on how organizations create the right behavior and mindset shifts, which we have found useful [2].

The Case for Dropping MU Stages 2 and 3

May 17, 2014• 31

By DALE SANDERS

Physicians are lining up against Meaningful Use.

In a detailed letter sent this week to CMS Administrator Marilyn Tavenner and National Coordinator Karen DeSalvo, MD, the American Medical Association presented a long list of ideas to make Meaningful Use better for doctors.

The AMA warned that “unless significant changes are made to the current program and future stages,” doctors will drop out of the meaningful use program, patients will suffer as existing EHRs fail to migrate data for coordinated care, thousands of doctors will incur financial penalties, and new delivery models requiring data will be jeopardized.”

All of which is true. But the AMA didn’t go far enough.

Meaningful use is well intentioned, but like a teacher who “teaches to the test,” the program has created a byzantine system that might pass the test of meaningful use stages, but is not producing meaningful results for patients and clinicians.

A formal study published in the April 2014 issue of JAMA Internal Medicine reveals there’s no correlation between quality of care and meaningful use adherence. This study validates what common sense has told many of us for the last few years.

Meaningful Use Stage 1 was a jump-start for EMR adoption in the industry. That’s a good thing, I suppose, although meaningful use also created a false economic demand for mediocre products. It’s time to put an end to the federal meaningful use program, eliminate the costly administrative overhead of meaningful use, remove the government subsidies that also create perverse incentives, and let “survival of the fittest” play a bigger part in the process.

Let the fruits of EMR utilization go to the organizations that commit, on their own and without government incentives, to maximizing the value of their EMR investments toward quality improvement, cost reduction, and clinical efficiency.

Harvard MOOC: Patient Safety and Quality with Ashish Jha

May 15, 2014• 22

By Ashish Jha, MD

Last year, about 43 million people around the globe were injured from the hospital care that was intended to help them; as a result, many died and millions suffered long-term disability. These seem like dramatic numbers – could they possibly be true?

If anything, they are almost surely an underestimate. These findings come from a paper we published last year funded and done in collaboration with the World Health Organization. We focused on a select group of “adverse events” and used conservative assumptions to model not only how often they occur, but also with what consequence to patients around the world.

Our WHO-funded study doesn’t stand alone; others have estimated that harm from unsafe medical care is far greater than previously thought. A paper published last year in the Journal of Patient Safety estimated that medical errors might be the third leading cause of deaths among Americans, after heart disease and cancer.

While I find that number hard to believe, what is undoubtedly true is this: adverse events – injuries that happen due to medical care – are a major cause of morbidity and mortality, and these problems are global. In every country where people have looked (U.S., Canada, Australia, England, nations of the Middle East, Latin America, etc.), the story is the same.

Patient safety is a big problem – a major source of suffering, disability, and death for the world’s population.The problem of inadequate health care, the global nature of this challenging problem, and the common set of causes that underlie it, motivated us to put together PH555X.

It’s a HarvardX online MOOC (Massive Open Online Course) with a simple focus: health care quality and safety with a global perspective.

Introducing PH555X: Improving Global Health: Focusing on Quality and Safety

May 15, 2014• 6

[youtube]http://www.youtube.com/watch?v=00wx9NaGA8g[/youtube]

Another Step toward Open Health Education

May 14, 2014• 17

By Gaglani, Haynes & Painter

Earlier this month Shiv and Ryan published a piece in the Annals of Internal Medicine, entitled What Can Medical Education Learn from Facebook and Netflix? We chose the title because, as medical students, we realized the tools our classmates are using to socialize and watch TV use more sophisticated algorithms than the tools we use to learn medicine.

What if the same mechanisms that Facebook and Netflix use—such as machine learning-based recommender systems, crowdsourcing, and intuitive interfaces—could transform how we educate our health care professionals?

For example, just as Amazon recommends products based on other items that customers have bought, we believe that supplementary resources such as questions, videos, images, mnemonics, references, and even real-life patient cases could be automatically recommended based on what students and professionals are learning in the classroom or seeing in the clinic.

That is one of the premises behind Osmosis, the flagship educational platform of Knowledge Diffusion, Shiv’s and Ryan’s startup. Osmosis uses data analytics and machine learning to deliver the best medical content to those trying to learn it, as efficiently as possible for the learner.

Since its launch in August, Osmosis has delivered over two million questions to more than 10,000 medical students around the world using a novel push notification system that syncs to student curricular schedules.

Osmosis is aggregating medical school curricula and extracurricular resources as well as generating a tremendous amount of data on student performance. The program uses adaptive algorithms and an intuitive interface to provide the best, most useful customized content to those trying to learn.