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The Medical Home’s Humpty Dumpty Defense

Mar 6, 2014• 22

By Michael L. Millenson

I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.

The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.

That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”

Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!

But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”

In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.

It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?

Obamacare’s Payment Pilots Are Struggling To Prove They Work. Here’s Why It’s OK.

Mar 5, 2014• 4

By DAN DIAMOND

When Barack Obama was merely a senator running for the White House, he told one physician association, “I support the concept of a patient-centered medical home” and would encourage the model if he ever became president.

Six years later: Mission accomplished.

Nearly 7,000 primary care practices have officially been accredited as PCMHs, and thousands of other providers have adopted some features of medical homes, which use a team-based approach to coordinated care. And while the movement toward medical homes might have evolved without Obama, his health reforms clearly laid the groundwork for rapid adoption.

The only problem? There’s still no clear evidence that the model even works.

A prominent Journal of the American Medical Association study last month found that after three years, one of the nation’s largest medical home pilots didn’t lead to lower costs or significantly higher care quality.

“There are folks who believe the medical home is a proven intervention that doesn’t even need to be tested or refined,” lead study author Mark Friedberg told the Wall Street Journal‘s Melinda Beck. “Our findings will hopefully change those views.”

An accompanying editorial also sounded caution. “It is time to replace enthusiasm and promotion with scientific rigor and prudence,” Thomas Schwenk wrote, “and to better understand what the PCMH is and is not.”

CDC: Together We Can Provide Safer Patient Care

Mar 4, 2014• 32

By Tom Frieden, MD

There are many stories of patients who suffer when we make errors prescribing antibiotics. 75-year-old Bob Totsch from Coshocton, Ohio, went in for heart bypass surgery with every expectation of a good outcome.

Instead, he developed a surgical site infection caused by MRSA. Given a variety of antibiotics, he developed the deadly diarrheal infection C. difficile, went into septic shock, and died.

A tragic story and, probably, a preventable death.

Today, we’ve published a report about the need to improve antibiotic prescribing in hospitals. Antibiotic resistance is one of the most urgent health threats facing us today. Antibiotics can save lives.

But when they’re not prescribed correctly, they put patients at risk for preventable allergic reactions, resistant infections, and deadly diarrhea. And they become less likely to work in the future.

About half of hospital patients receive an antibiotic during the course of their stay. But doctors in some hospitals prescribe three times more antibiotics than doctors in other hospitals, even though patients were receiving care in similar areas of each hospital.

Among 26 medical-surgical wards, there were 3-fold differences in prescribing rates of all antibiotics, including antibiotics that place patients at high risk for developing Clostridium difficile infections (CDI).

CDC has estimated that there are about 250,000 CDIs in hospitalized patients each year resulting in 14,000 deaths.

Where There’s Vapor, Is There Fire? We Need Evidence on E-Cigarettes

Mar 4, 2014• 12

By Shadel, Tucker & Martino

One thing that is known about electronic cigarettes: they’ve become a serious business in the United States.

Although e-cigarettes represent only a tiny percentage of the U.S. tobacco market, the industry is growing.

The number of people currently “vaping” has increased substantially over the last few years, with sales of nearly $2 billion in 2013.

Some analysts predict that this could grow to $10 billion by 2017 and eventually overtake sales of conventional cigarettes. It’s worth noting that the industry is maturing without much in the way of oversight or regulation.

We also know how e-cigarettes work—mechanically speaking. Using a battery-powered heating element, they convert liquid nicotine (sometimes flavored with food additives) into a vapor that users then inhale or “vape.”

This unique system delivers nicotine without the cancer-causing and other harmful elements associated with burning tobacco.

Unfortunately, that’s where a lot of the certainty ends. Currently, evidence for the safety, harmfulness, utility, and addictiveness of e-cigarettes is lacking.

The questions that research needs to answer, however, are clear as day—particularly since business is booming.

Are E-Cigarettes Bad for You?

Some of the food additives that flavor e-cigarette vapor may be dangerous when inhaled; the long-term health effects of inhaling the vapor are unknown. And of course, e-cigarettes still deliver nicotine, the main addictive ingredient in cigarettes and other tobacco products.

Nicotine from e-cigarettes could have detrimental effects on cardiovascular health and may impair breathing among those with already compromised lung functioning.

Primary Care 2.0: A Vision for a Transformative Solution

Mar 3, 2014• 13

By Paul Keckley

There’s scant disagreement that a key to transforming the U.S. health system is strengthening its primary care foundation. But there’s no consensus about how.

In last week’s new cycle, evidence of our dysfunction on this central issue was apparent:

Last Monday, the American Academy of Pediatrics fired a volley across the bow at retail clinics, calling them an “inappropriate source of primary care for pediatric patients (1).” Instead, the society that represents the nation’s 62,000 pediatricians encouraged an alternative—the patient centered medical home it originated in 1967.

In its policy statement, while acknowledging the growing popularity of retail clinics, the AAP affirmed its opposition to models that are not physician driven. Never mind that the 1600 retail clinics deliver comparable outcomes for treatment of a dozen uncomplicated medical problems, offer extended hours and cost less than half for a medical office visit. And their caregivers are nurse practitioners.

Then Tuesday, a robust Canadian study was released that cast doubt on the suitability of the patient centered medical home (PCMH) as the transformative model for primary care (2). The Canadian research team compared results from 32 medical home practices in Pennsylvania that had achieved certification from the National Committee on Quality Assurance’ medical home program to 29 non-medical home primary care practices in the same region from 2008-2011.

They concluded “a multi-payer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement (3).”

And the same day, the White House announced it would spend $5.2 billion over 10 years to train 13,000 additional primary care residents and $3.95 billion over 6 years to expand the Health Resources Services Administration (HRSA) program from 8900 primary care providers to 15,000.

Just a Flesh Wound

Mar 3, 2014• 3

By MILES O’BRIEN

I wish I had a better story to tell you about why I am typing this with one hand (and some help from Dragon Dictate).

A shark attack would be interesting. An assassination attempt would be intriguing. Skydiving mishaps always make for good copy. An out-of-control quad copter that turns on its master would be entertaining (and would come complete with a grim, potentially viral, video).

No, the reason I am now one-handed is a little more prosaic than those scenarios.

I had finished my last shoot after a long reporting trip to Japan and the Philippines and was stacking the Pelican cases brimming with TV gear onto my cart. As I tried to bungee cord them into some semblance of security for movement, one of the cases toppled onto my left forearm. Ouch! It hurt, but I wasn’t all “911” about it. It was painful and swollen but I figured it would be okay without any medical intervention. Maybe a little bit of denial?

The next day, February 13, things seemed status quo. It was sore and swollen but seemingly no worse. Then, that night, things got worse. Both the pain and swelling increased.

So on the morning of February 14, I asked the hotel for a referral to a doctor and went to see him right away. While my concern was already growing, the look on his face when he saw my forearm got me a little more nervous.

The doctor told me he suspected that I might be having an Acute Compartment Syndrome. I had to Wiki it, but in essence it is an increase in pressure inside an enclosed space in the body. This can block blood flow causing a whole host of serious, life-threatening consequences.

He had me admitted to the hospital. Over the next few hours, I endured probably the longest, most painful experience I could ever imagine. My forearm developed some dusky discoloration, but more alarming was the numbness. I could not feel my forearm!

The doctor recommended an emergency fasciotomy to relieve the pressure. This is a gruesome enough procedure on its own, but the he was clear that the problem was progressing rapidly and there was a clear and present threat to my limb.

How Reliable Are EMR Reviews, Anyway???

Mar 3, 2014• 8

By THCBist

The dude writes:

“I’m looking into a new EMR for our just incorporated small group practice. I’m diligently doing my Google research. Frankly, I’m not at all impressed by the quality of the information I’m finding out there. Both the professional and the customer reviews I’m finding leave a lot to be desired.

The tone of many of the reviews I’m reading makes me wonder how reliable and objective they are. A suspicious number of customer reviews are blandly positive, as if they were written by a corporate drone in a cubicle somewhere. They’re full of industry buzzwords and praise: “Met all of my expectations ” and “is everything I could ask for in an EMR system.”

I’ve read enough patient and restaurant reviews online to know that reviews generally fall into two categories: angry customer and worshipful. The former almost always outnumber the latter by a margin of 4:1 But not here. Here its the other way around! The tone of the professional reviews also seems strangely subdued.

At least one popular review site (Software Advice) appears to take a direct commission from EMR vendors for each referral. They say this doesn’t impact them and that they’re objective, but this clearly biases them in my mind. What resources do people recommend?

And why doesn’t THCB run user reviews???

On THCB This Week

Mar 2, 2014

By THCBist

Narrow Networks: Boon or Bane?

Bigger Hospitals Mean Bigger Hospitals with Higher Prices. Not Better Care.

Metrics: Surprisingly, people who were uninsured last year remain undecided about the ACA,

Clinic: A cautionary note about the risks of blood pressure treatment in the elderly.

In Defense of corporate wellness programs.

Do workplace wellness programs make business sense?

Doctors without (state) borders.

Amazon.com as a delivery model for population health.

How Mayo Clinic is using iPads to empower patients.

Can Oscar succeed in making health insurance fun? Maybe not just yet ….

That vitamin over there could kill you.

How Reliable are EMR reviews, anyway???

Transparency a go go …

CVS Caremark is entering CommonWell.

Seven reasons your doctor is still using technology that sucks.

Are payors changing what they’re are paying for medical billing codes to adjust for supply and demand?

What you need to know about patient matching and your privacy and what you can do about it.

Why Everything You Know about Health Care in China Is Wrong

Mar 2, 2014• 4

By Damjan Denoble

Two announced hospital deals — Fosun Pharma’s (复星医药) announced acquisition of Chindex International, Ltd., and a partnership between Evergrande Real Estate Group (恆大集團) and Harvard’s Brigham and Women’s Hospital– have generated much discussion in niche investors and analyst communities about how much, or how little, investors should be excited about the possibility that China’s healthcare service sector is open to investment.

In point of fact, these two deals are not cause for optimism. Rather, they are the story of the inability of healthcare services in China to make a profit writ large.

With few very minor exceptions, and the reputations of Chindex and Harvard notwithstanding, no single institution in China has yet figured out how to make hospitals, and more generally, healthcare services, profitable in China in the long term[1]; not the Chinese government, not private Chinese firms, not the semi-foreign companies from Taiwan-Macao-Hong-Kong, and certainly not truly foreign firms from other Western countries.

Moreover, it is very unlikely that a sustainable profit model is a real possibility in the short to mid-term. China’s mix of government policies and ministry regulations disadvantage private health service institutions in the marketplace through discriminatory tax treatment relative to public hospitals, market entry limitations that force private hospitals into underdeveloped population zones and stall expansion projects, as well as various other acts that make it difficult for private health providers to compete with public hospitals in the recruitment of capital and medical staff.

Until last week at least, despite these challenges, the United States could claim one successful and prominent entry in China’s private healthcare arena – the United Family Care family of hospitals and clinics, run by Chindex International, Inc. Chindex opened Beijing United Family Hospital in 1994, and since then opened up several more clinic branches across China, including the United Hospital in Shanghai [2].

However, when Shanghai Fosun Pharmaceautical Group Co Ltd (from here on out “Fosun Pharma”) announced that it was partnering with equity house TPG Capital to acquire Chindex in a deal valued at $369 million, the United States lost this single claim to success in China’s healthcare services market.

The deal, when finalized, will give Fosun Pharma majority ownership of Chindex, result in Chindex becoming a private company, and will turn the beacon of American success in the Chinese healthcare industry into a subsidiary of a Chinese conglomerate.

Metrics: Surprisingly, People Who Were Uninsured Last Year Remain Undecided About the ACA

Mar 1, 2014• 7

By Katherine Grace Carman

Since mid-December, we’ve brought you the latest data on public opinion of the Affordable Care Act (ACA) from the RAND Health Reform Opinion Study (RHROS), a new way to measure public opinion of health reform. The RHROS allows us to observe true changes in opinion by surveying the same people over time.

The trend of overall stability masking churn in individual opinion that we discussed last week has continued with our latest data. This week, however, we delve deeper to look at differences in opinion between two groups: those who had insurance in 2013 and those who did not.

Understanding how the ACA impacts these groups differently is particularly important. While the ACA is currently changing the landscape of health insurance, its impact should be especially pronounced for Americans who lacked access to insurance through their employer or government programs in 2013.

The following graph illustrates the opinions over time of all individuals who had insurance, regardless of the source.

This includes those who had coverage through their employer, purchased it on the private market, or received it through a variety of government programs, such as Medicare and Medicaid.

This group represents about 85 percent of the overall sample.

This graph shows opinion of the ACA among those who were uninsured in 2013:

At first glance, what’s striking about these two graphs is how similar they are—more on that in a moment—but there are actually some very important differences.