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Are Young Doctors Failing Their Boards? Or Are We Failing Them?

Jul 2, 2013• 26

By David Shaywitz, MD

A short piece in The Health Care Blog reveals (albeit unintentionally) why so many outside of healthcare think the medical establishment still doesn’t get it.

The post, written by a general internist and residency program director, asked why an increasing number of internal medicine doctors are failing their internal medicine board exams. The pass rate has reportedly declined over the last several years from 90% to 84%. (Disclosure: I passed this required test about a decade ago.)

His differential included two possibilities:

(1) The test is getting harder – The testing agency said this wasn’t the case.

(2) Millennials lack the study habits of their elders, and have become great “looker-upers.” – The author suggested this was a key factor, and several commentators enthusiastically agreed.

The basic thesis here that in the Days of Giants, doctors worked harder, learned more, and were better. Nowadays, doctors are relatively complacent, less invested, less informed, and are generally worse – which is what’s reflected on the board exams.

Let me suggest a third possibility – perhaps today’s doctors are providing better care to patients than their predecessors were a generation ago. Maybe today’s doctors have figured out that in our information age, your ability to regurgitate information is less important than your ability to access data and intelligently process it. Maybe what makes you a truly effective doctor isn’t your ability to assert dominance by the sheer number of facts you’ve amassed, but rather how well you are able to lead a care team, and ensure each patient receives the best care possible.

In other words, what if the problem isn’t the doctors, who are appropriately adapting, but rather the tests (and the medical establishment), which may not be?

Can a Portable Hand Sanitizer System Reduce Hospital-Acquired Infections in America’s Hospitals?

Jul 1, 2013• 6

By Mike Miesen

Ignaz Semmelweiss was laughed out of his Viennese hospital when he suggested that physicians should wash their hands in between conducting an autopsy and delivering a baby.

150 years later, we know just how right he was, but hand sanitation compliance rates at hospitals still hover in the 30% to 50% range. This makes it easy for hospital-acquired infections (HAIs) such as MRSA and VRE to run rampant, a (literally) dirty, not-so-little, and not-so-secret reality for American patients.

A Healthbox-backed startup is trying to change that. SwipeSense, founded in 2012 by Northwestern University graduates Mert Iseri and Yuri Malina, is a system designed to improve sanitation practices in hospitals using portable hand sanitizers and wirelessly-collected data on their use.

The organization wants to help stem the tide of avoidable HAIs. Each year, about 100,000 Americans die from infections they contract during their time in the hospital – more than the number of Americans killed by guns, motor vehicles, and leukemiacombined. In addition to the direct human toll, HAIs cause patient length of stays to increase by 8.0 days in ICUs and 7.4 to 9.4days in acute care wards, taking up expensive capacity and preventing others from accessing needed hospital beds. They’re also expensive, causing an estimated $4.5 to $5.7 billion in excess costs.

Iseri and Malina were inspired to create SwipeSense by a project they did for Design for America, a student group created to catalyze social change using human-centered design (also founded by Iseri and Malina). It took them to Northwestern Memorial University Hospital in their college town of Evanston, Illinois, where they identified two salient issues with hand sanitation: convenience and compliance.

“It’s obvious it’s not the fault of the nurse or physician…it’s something wrong with the system,” Malina told me in an interview. Even though alcohol foam and soap dispensers are ubiquitous in American hospitals, they often aren’t at the immediate point of care: “medical staff need to sanitize four or five times per patient encounter,” Malina said, making proper sanitation an arduous, time-consuming, and unrealistic task. “Our philosophy at SwipeSense is that the right thing to do should be the easiest thing to do… We want to make something that people love.”

Not Walking Away From Medicare

Jul 1, 2013• 12

By Leslie Kernisan, MD

This past week, the NYT New Old Age Blog featured a post about me and my practice. Titled “Walking Away from Medicare,” it describes my decision to opt-out of Medicare and create a different kind of geriatric practice.

It has generated quite a lot of comments: 163 at my latest count. Most of them judge me pretty harshly. It seems that many people feel that I’m doing this for the money. And that I don’t care about society or older people.

Of course, if you know me or if you’ve been reading this blog, then you’ll know that nothing could be further from the truth. My practice is fairly small, in part because my goal in having this practice was to have a way to keep working with patients and families, while having the flexibility to pursue my other professional interests. Since I started the practice, I’ve spent most of my time writing for this blog, learning about the worlds of digital health and healthcare innovation, and thinking about how we can teach geriatrics directly to caregivers.

Why Are So Many Younger Doctors Failing Their Boards?

Jul 1, 2013• 23

By John Schumann, MD

An interesting conversation recently took place among residency program directors in my field of Internal Medicine.

At issue was the declining pass rate of first-time test takers of the ABIM Certification Exam.

It’s a mouthful to say, but the ABIM exam is the ultimate accolade for internists; one is only eligible to take the exam after having successfully completed a three-year residency training period (the part that includes “internship,” right after medical school).

An easy analogy is to say that the board exam is for a doctor what the bar exam is for a lawyer. The difference is that a doctor can still practice if s/he does not pass–they might be excluded from certain jobs or hospital staffs; but certification, while important, is a bit of gilding the lily. [Licensure to practice comes from a different set of exams.]

There’s no doubt it’s a hard test. I was tremendously relieved to have passed it on my first try. Over the last few years, the pass rate for first time takers has fallen from ~90% to a low of 84%.

It may not seem significant, but for 7300 annual test takers, the difference in pass rates affects about 365 people–or one additional non-passing doctor for every day of the year.

In any event, we program directors have taken note. And the falling pass rate has raised questions:

Has the test increased in difficulty? No, says the ABIM.
Are the study habits of millennials not up to the level of Baby Boomers and Gen X’ers? Now you may be on to something.

Fast Food Economics: How Medium Became the New Large

Jul 1, 2013• 9

By Lisa Young

As a nutrition researcher tracking portion sizes and labels manufacturers use to describe such sizes, I have seen food portions not only grow larger over the years, but the labels to describe foods and drinks have also changed.

For example, when McDonald’s opened in the 1950s, the company offered one size soda, which was 7 ounces; today’s 12 ounces is labeled a kid’s size and the 16-ounce is labeled small. Similarly, when Burger King opened, the company offered a 12-ounce small and a 16-ounce large soda. The 12-ounce is no longer sold and the 16-ounce comes as part of the value meal. Burger King’s small soda is now 20 ounces, the medium is 30 ounces, and the large is 40 ounces.

Does anyone pay attention to these label descriptors? And do they influence how much we really eat? Apparently yes, according to a new study published in Health Economics by Cornell University researchers David Just and Brian Wansink.

The study found that labeling a food as “regular” or “double size” affects how much consumers will eat, regardless of how big or small the portion size actually is.

The researchers served subjects two different portions of pasta in either a one cup-portion or a two-cup portion. For some of the subjects, the two different size portions were labeled “half-size” and “regular.” For the other subjects, the identically-sized portions were labeled “regular” and “double-size.” The labels for the first group of subjects indicated that the two-cup pasta portion was the regular size, while it was suggested to the second group of subjects that the one-cup pasta portion was the regular size.

The study concluded that varying the “regular” portions affected how much the subjects actually ate. Subjects ate more food when the portion was labeled “regular” than when it was labeled “double-size” despite the fact that the two sizes were actually the same size.

The subjects were also willing to pay more for a larger sounding portion size.

A Time of Change at the American Board of Internal Medicine

Jul 1, 2013• 2

By Bob Wachter, MD

Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…

Would We Be Better Off If Employers Stopped Paying for Health Insurance?

Jun 30, 2013• 16

By Uwe Reinhardt

In his “Are Employers to Blame for Our High Medical Prices?,” David Dranove takes issue with my statement in a New York Times blog post:

“One reason for the employers’ passivity in paying health care bills may be that they know, or should know, that the fringe benefits they purchase for their employees ultimately come out of the employees’ total pay package. In a sense, employers behave like pickpockets who take from their employees’ wallets and with the money lifted purchase goodies for their employees.”

He writes:

“The correct economic argument is a bit more nuanced. Employees do not care about the cost of their benefits; they care about the benefits. If an employer can procure the same benefits at a lower cost, the employer need not increase wages one iota. In this regard, there is nothing special about health benefits. Suppose an employer offers employees the use of company cars. Workers don’t care what the employer paid for the cars, and if the employer can purchase cars at a deep discount, it will pocket the savings.”

So far I can buy the nuance. It is something we could theorize about.

But then David he notes that:

“Employers may have an incentive to reduce benefits costs yet they are passive purchasers. With a few exceptions, nearly every American corporation outsources its healthcare benefits to insurers and ASO providers and then looks the other was as the medical bills pile up. Sure, they complain about the high cost of medical care, but they don’t take direct action by aggressively shopping for lower provider prices. Doesn’t this passivity demonstrate a lack of interest? No more so than the fact that auto makers do not aggressively shop the lowest rubber or silica prices implies that they are disinterested in the costs of tires and windows. Auto makers outsource the production of tires and windows (and most other inputs) and let the Michelins and PPGs of the world worry about rubber and silica prices. By the same token, American companies outsource the production of insurance and let the Blues and Uniteds of the world worry about provider prices. This is entirely appropriate.”

Forgive me if by now I am lost. Do we really believe that modern corporations, whose management and board of directors agonize even over an extra penny of earnings per share (EPS) – believe me, I know whereof I speak – simply outsource the procurement of major inputs and then look the other way?

They do seem to do it in health care – which is the puzzle – but they surely do not in connection with other important inputs where smart buying can add pennies to EPS.

Can Hospitals be Sued for Excessive Markups on Medications and Devices?

Jun 30, 2013• 3

By ALEX STEIN

Steven Brill’s TIME MAGAZINE blockbuster article, Bitter Pill: Why Medical Bills are Killing Us, uncovers the CHARGEMASTER: a publicly undisclosed pricelist accountable for what we see in hospital bills. What we see there doesn’t look good: it includes acetaminophen sold for $1.50 a tablet (you can buy 100 of those for the same price at Amazon); $77 for a box of sterile gauze pads (Amazon’s prices vary between $6 and $11); $18 for a single diabetes test strip (sold for 54 cents by Amazon); $108 for antibacterial Bacitracin ointment (Amazon’s prices vary between $2.50 and $6.50); and so forth. Charges for stay, scans, surgeries, canes, and wheelchairs skyrocket as well.

The American Hospital Association (AHA) rejects Brill’s analysis. According to AHA, the chargemaster aggregates the hospital’s overall costs on delivering quality care to patients: “In order to take medications in a hospital, even over-the-counter medicines, they must be prescribed by a doctor (a little bit of cost for the doctor), that order gets transmitted to the pharmacy (a little more cost), the order gets filled by a pharmacist or pharmacy tech who retrieves just one Tylenol pill and individually packages that one pill (still more cost), the pill gets transported from the pharmacy to the nursing unit where the patient resides (a little more cost), then the pill is retrieved by a registered nurse who personally gives the pill to the patient and then must document the administration of that pill in the patient medication administration record (a little more cost). All of this process to give a patient a single dose of Tylenol in a hospital bed [must also be] in compliance with all pertaining regulations (a little more cost).”

This post will not try to resolve the Tylenol Debate. Nor will it say anything about the government as a plausible substitute for the eccentric chargemaster. Instead, I will raise a legal question: Can patients sue hospitals for excessive markups on medications and devices?

My answer to this question is a qualified YES.

Entrepreneurial and business aspects of running a hospital fall under states’ consumer protection laws (Brookins v. Mote, 292 P.3d 347 (Mont. 2012)). Those aspects certainly include billing (Jaramillo v. Morris, 750 P.2d 1301, 1304 (Wash. App. 1988); Ambach v. French, 216 P.3d 405 (Wash. 2009)).

The key question here is whether an excessive markup on medications and devices amounts to deceit or an unfair trade practice. If it does, the hospital would be in violation of the relevant state consumer protection law.

Yes. Employers Really Are to Blame For Our High Medical Prices

Jun 29, 2013• 43

By Uwe Reinhardt

I welcome Leah Binder’s earlier post on this blog, written in response to my blog post in The New York Times. To be thus acknowledged is an honor.

As an economist, I am not trained to respond to Ms. Binder’s deep insights into my psyche, dubious though it may be. Nor, alas, can I delve into hers, fascinating though that might be. Let me therefore concentrate instead just on substance.

First of all, I do not recall calling employers “stupid,” nor did I question their IQ. I do confess to having once called employee benefits managers, when addressing them at some of their usually mournful meetings, “kind-hearted social workers dressed to look like tough Republicans.” At that meeting I contrasted how carefully their company’s tough-minded VP for Procurement, Murgatroid de B. Coverly III, Princeton ’74, purchased paper clips for the company with the much more mellow approach taken by their V.P. of Human Resources to purchase health care for their company’s employees.

Benefit managers – I hate to call them BMs — really are the nicest folks. They care deeply about their employees’ well being (until, of course, the latter lose their job with the company). They worry incessantly about their company’s ever rising outlays for health insurance. And, after a cocktail or two, they regularly lament how rarely they get the attention of top management and of the board of directors – the very folks I once told to go look into a mirror in their search for the culprit behind rising health care costs.

No, when I say “employers” I really mean top management and boards of directors who make the rules. And I did not even call those mighty ones stupid, but merely “passive payers” as did, by the way, David Dranove on this blog in his critical response to my New York Times piece. Why these usually tough and smart people have behaved so passively in buying health care for themselves and their employees remains a puzzle at the level of economic theory.

Three Reasons Uwe Reinhardt Blames Purchasers for Everything

Jun 28, 2013• 39

By Leah Binder

Uwe Reinhardt is one of the nation’s most respected health care economists, professor at the prestigious Woodrow Wilson School at Princeton, fellow of the Institute of Medicine, and one of the shining lights in health policymaking circles.

But alas, even the best and the brightest are wrong sometimes. Case in point: Reinhardt’s recent comments in the New York Times on the role of the American business community in fueling our nation’s health care problems. To paraphrase, Reinhardt believes that employer purchasers of health care are 1) dim bulbs and 2) responsible for the escalating costs of care.

This seemed puzzling coming from Reinhardt, whose views are widely respected by purchasers. But I was able to diagnose the problem by drawing on insights from social psychology.

Social psychology investigates “attribution,” our mind’s process for inferring the causes of events or behaviors. It’s how we describe why things happen — to us or to someone else. It turns out, we humans aren’t very accurate in our attribution processes because all of us suffer from at least one of the following problems. In his New York Times piece, poor Professor Reinhardt appears afflicted by all three at the same time. Let’s take a closer look at each:

1. Actor-Observer Bias: This is the notion that when it comes to explaining our own behavior, we tend to blame external forces more often than our own personal characteristics.

Reinhardt is rightfully troubled by a decade of escalating health care cost growth under employment-based health insurance. But seized by Actor-Observer Bias, Reinhardt blames this problem not on the world of health care that he played such an influential role in over the past few decades, but on external forces, the employers who purchase health care.