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If You Want to Stop Hospital Harm, Don’t Call a Capitalist

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By MICHAEL MILLENSON

The Leapfrog Group has just released its latest report grading the safety of hundreds of individual hospitals, but the real news isn’t the“incremental progress.” It’s how a group started by some of the most powerful corporations in America has quietly devolved into just one more organization hoping press releases produce change.

Amid the current enthusiasm for “value-based purchasing” by employers and possible privatization of Medicare, it is worth examining why Leapfrog’s initial notion that corporations would spearhead a crackdown on crummy care failed and what we can learn from that publicly unacknowledged failure.

Leapfrog was launched with the hoopla of a high-powered initiative. A widely publicized 1999 report by the Institute of Medicine declared that up to 98,000 patients die every year in hospitals from preventable errors and more than one million are injured. In November, 2000, the newly formed Leapfrog Group announced three targeted “leaps” in patient safety that promised to save some 58,000 lives, prevent a half million medication errors and (in calculations that came later) save billions of dollars.

“The number of tragic deaths brought about by preventable medical errors is too striking for those of us in the business community to ignore,” declared Lewis Campbell, chairman and CEO of Textron TXT -0.29%, at the group’s launch.

Campbell was head of a health care task force of the Business Roundtable, an elite group of corporate leaders that sponsored Leapfrog. Wielding the power of the checkbook to enforce “aggressive but feasible target dates” was “a straightforward business approach to tackling a complex problem,” Campbell explained.

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Using Price Transparency Data Within the Hospital

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By David Halpert, MD

Last week, CMS unilaterally released chargemaster data from 300 hospitals around the country. As David Dranove summed up well in his recent piece, this is an old hat. Yes, there are big variations in hospitals’ chargemasters. And yes, there is a lot of buzz around consumer price shopping.

A Kayak for hospitals is all well and good, but hospitals are cash-strapped as it is and there is only so much money to be saved by driving down the costs the hospital charges the health care plan unless the waste within the hospital is addressed. I would like to highlight perhaps one of the most exciting things going on under the radar in US healthcare today: using price transparency data within the hospital.

Hospitals are now reimbursed a capitated amount according to each patient’s diagnostic-related group. Capitated payment means, essentially, that the hospital receives a set amount of dollars for each patient that walks through its doors with a given diagnosis — say, $X for a patient with pneumonia or $Y for a patient with MI. Regardless of how many drugs, tests, or scans the hospital uses for the patient, it will still get the same compensation from the insurance company.

Yet, the physician up until now still acts as a kid in a candy store, running up a bill without awareness of cost or value. This is largely because the doctor is ordering from a menu without prices. I have talked to many physicians, in both out-patient and in-patient settings across seven health care systems around the country — they want a menu with prices.

I have seen firsthand the motivation for this, as pay-for-performance model is beginning to take over with my own practice. Gone are the days where doctors’ salaries are unhitched to the cost-effectiveness of care. Everyone is now in the same boat.As a neurologist, I want to share a few examples regarding stroke care that illustrate the potential savings available from educating physicians regarding cost, and also some pitfalls to avoid that could compromise patient care.

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When Private Hospitals Cherry-Pick, Teaching Hospitals Pay the Price

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By Joanne Conroy, MD

I always believed that, if we could harness the entrepreneurial spirit of the American physician, we could be capable of great things. Physician decisions drive much of what is good and bad about our health care system. Their pens are the biggest driver of cost and their vigilance is the most significant driver of quality. It is a shame that physician-owned hospitals are accelerating the creation of a two-tier system by cherry-picking healthy, well-insured patients.

There are overwhelming monetary incentives for physician-owned hospitals to market to the healthiest and wealthiest, who seek a narrow list of procedural interventions. But then those physicians are rewarded with value-based payments for high satisfaction scores and low readmission rates as mandated by the Affordable Care Act.

What happens to the rest of the patients—the ones with one if not several chronic conditions and minimal if any insurance?

They find their way to teaching hospitals, which treat a disproportionate number of “dual eligibles” (seniors so poor they need both Medicare and Medicaid support), the disabled, and nonwhite patients. Teaching hospitals can quickly become underfunded and over-stretched, offering opportunities for physician-owned hospitals in the market to deliver better quality, albeit more expensive, health care to those who have the ability to choose. In spite of that, many teaching hospitals deliver excellent service and care.

In a May 14 Wall Street Journal article, Alicia Mundy wrote, “Doctor-owned hospitals are largely privately held, so it’s difficult to know their profit margins, despite the law’s growth restrictions. According to the American Hospital Directory, a private firm that provides data about some 6,000 U.S. hospitals, many physician-owned hospitals have enjoyed 20 to 35 percent profit margins in recent years.”

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New Developer Contest: Create a Cancer Survivor Tool

By Adam Wong, ONC and Abdul Shaikh, NCI
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ONC and the National Cancer Institute (NCI) are challenging app developers to create new tools to help cancer survivors. The new Crowds Care for Cancer: Supporting Survivors Challenge is asking app developers to create new tools meant to help survivors manage their care after they have completed cancer treatment.

HHS has had a series of developer contests that have spawned the creation of tools and apps to help patients and doctors better manage care. Some past app challenges include:

  • the Million Hearts Risk Check Challenge
  • the Blue Button Mash Up Challenge, and
  • the Ensuring Safe Transitions Challenge.

Cancer patients need more care coordination

The number of cancer survivors in the United States is currently estimated at 14 million people. With improvements in cancer screening, diagnosis, and treatment, as well as the aging of the United States, this number is expected to rise.

While celebrating advances in cancer care, there remains a need to help patients manage their health after they have completed their primary treatment. Cancer survivors experience a host of physical and psychosocial long-term and late effects of the disease, and it’s the treatment of this that requires coordinated follow-up care.

Despite significant progress in cancer treatment, the complex and often fragmented state of end-of-treatment care may lead to harmful breakdowns in patient-provider communication. This can result in unmet health care needs. Better communication, data exchange, and care coordination have been shown to help the patients.

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Wal-Mart Could Transform Care–But Does It Want To?

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By Dan Diamond

“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.

“Wal-Mart’s in retail, we’re not in health care.”

But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.

Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.

Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.

Background: Wal-Mart’s Growing Role in U.S. Health Care System

In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.

“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”

And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care.Continue reading…

Thank You, Angelina

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By JAMES SALWITZ, MD

Dear Ms. Jolie,

Thank you for your bravery and leadership in the battle against breast cancer. In a small way, through my patients, I understand the challenge and pain it took not only to undergo prophylactic mastectomies, because you carry the BRCA1 cancer gene, but also to reveal this deeply personal part of your life to the world (NYT, 5/14/13; My Medical Choice). You had no obligation to open your soul; your selfless act leaves those of us that treat the dread disease, in awe.

Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years. By opening up the conversation, by educating and by boldly stating that beauty, strength and health are possible, even when radical choices are made, you open up life saving opportunities for many. Mastectomies may not be the answer for all women, but the very idea that cancer can be prevented, instead of simply waiting in fear, is earth shattering.

Women and men will now better understand the genetic risks for cancer, be exposed to the different options which are available in the prevention of cancer and know that it is possible, whatever path is taken, to continue with full lives. You have made it easier for patients, their families and physicians to have vital discussions.

The announcement of your surgery coincides with a critical legal battle, the deliberations of the United States Supreme Court regarding BRCA genetic testing. You have put pressure on the Court to find against Myriad Genetics Corporation in the company’s attempt to protect their expensive monopoly of the breast cancer genetic assay. Thus, the Court will have the opportunity to reduce the cost of testing, which as you note, can run thousands of dollars per patient.

Your action changes the war against breast cancer. You have prevented the suffering of thousands and given them the opportunity to go on with life and be part of what is truly important, families and communities.

Thank you for your remarkable sacrifice.

Humbly,

James C. Salwitz, MD

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

Did Angelina Do the Wrong Thing?

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By SHIRIE LENG, MD

A woman’s mother dies at age 56. A blood test is done. The woman finds out she has a genetic pre-disposition to cancer. She takes what action she thinks she needs to take. A familiar story repeated over and over again every day. I’ve met many women who have made this choice. While not “normal”, it is a familiar situation. These women’s difficult choices go unheralded. But not Angelina. She has a voice and she’s not afraid to use it.

I am of two minds about Ms. Jolie’s announcement. Unlike double mastectomies for ductal carcinoma in situ (DCIS), which isn’t necessarily a cancer and can be treated with a lumpectomy, BRCA1 gene mutations can’t be treated any other way. Unless I hear differently from my breast surgeon friends, I’d say she probably did the right thing. Her decision to talk about it is probably encouraging to women who have or will have to make that choice. It raises awareness of the gene mutation. It puts breast cancer on the front page of the New York Times. Again.

Here’s my problem: double mastectomy is not a benign procedure. Ms. Jolie seems to have had a remarkably easy time of it. Yes, she says she was right back to her normal life soon after, but since Jolie’s life is not normal that’s hard to generalize. The truth is there is significant pain involved, a long period of waiting while the tissue expanders do their work, then there’s further procedures for the implants, which can develop capsules around them, or rupture, or get infected. If Angelina had chosen breast reconstructive surgery there would be the risk of the flap losing blood flow, multiple drains, overnight stays in recovery rooms or ICUs, and many many surgeries for revision, nipple creation, etc. And the results are not always beautiful. I understand that it is not Ms. Jolie’s role to scare people, but to encourage them. I would just warn against falsely rosy expectations.

I am not trying to discourage double mastectomy. Sometimes it is necessary. I do think that people who have extraordinary access to public attention must pay extraordinary attention to what they say. I wish Angelina all the best for a complete, and beautiful, recovery.

Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real.

The Leapfrog Group and the Spring 2013 Hospital Safety Score Release

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By Leah Binder

Q: Have hospitals improved since the first Hospital Safety Score last year?

A: We saw an incremental improvement in the scores, though it is not as rapid or as dramatic as we would like. For the Spring 2013 Hospital Safety Score, there were more than 2,500 general hospitals scored, including 780 “As,” 638 “Bs,” 932 “Cs,” 148 “Ds” and 16 “Fs.” Those hospitals that lowered their grades demonstrate how patient safety can be seriously impacted when hospitals don’t stay vigilant. Safety is a 24/7, 365-day effort with all hands on deck; there is no time for excuses when it comes to preventing errors, injuries and harm. On the other hand, hospitals that showed improvement should be celebrating. They have clearly accepted the challenge to improve and have proven that any institution can make significant advances in patient safety over a short period of time. Now, they need to work on sustaining that achievement into the future.

Q: How is the Hospital Safety Score different from other hospital ratings?

A: The Hospital Safety Score is the standard assessment of how well hospitals perform at protecting patients from accidents, errors and injuries. The Score is 100-percent transparent, and the only hospital safety assessment to be (favorably) peer-reviewed in the Journal of Patient Safety. Unlike any other rating, you can see all the data that was applied to every scored hospital, as well as the entire methodology. Also unlike many other ratings, the Hospital Safety Score highlights both the best and poorest performers on safety in an effort to educate consumers on the hospitals they rely on for care.

The Hospital Safety Score assesses hospitals strictly on patient safety. Each “A,” “B,” “C,” “D,” or “F” score assigned to a hospital comes from expert analysis of infections, injuries, and medical and medication errors that frequently cause harm or death during a hospital stay.

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Is the Online Health Clinic the Wave of the Future?

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By Jason Shafrin

HealthPartners argues that the answer is yes. In a 2013 Health Affairs article, they argue the following:

HealthPartners in Minnesota launched an online clinic called virtuwell in late 2010. After more than 40,000 cases, we report an average $88 lower cost per episode compared with care received in traditional settings, strong indicators of clinical effectiveness, and a 98 percent “would recommend” rating from customers. The possibility of extrapolating such savings to larger volumes of cases is compelling.

Although I believe that there will be some savings from online health clinics, I believe that much of this perceived savings is due to patients sorting. If relatively healthier patients use the online health clinic, then it could be the case that average costs will be lower for those who use the online services simply due to patient sorting. The report does risk adjust for patient comorbidities and other factors.

Risk adjustment, however, is always imperfect. Thus, three confounding factors could bias these estimates.

  1. Individuals who are more educated, wealthier, more technologically savvy are more likely to use the online health clinic, but are also more likely to be relatively healthy conditional on observables.
  2. Individuals who use the online clinics may be more likely to seek treatment for less severe cases. If this is the case, then the treatment received during the online clinic may appear cheaper than is really the case since treating this same people in the clinic may have been cheaper than the average patient. Thus, there would still be cost savingings but the magnitude would not be as large.
  3. Whereas the points above mention that there could be differences in the types of patients that use the online services, within each individual preferences for online treatment may vary. The less serious an illness appears to be (i.e., the lower the likelihood urgent care is needed from the patient’s perspective) the more likely individuals will seek online care.

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Hacking Healthcare

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By Fred Trotter

There are two definitions of the word “Hacker”. One is an original and authentic term that the geekdom uses with respect. This is a cherished label in the technical community, which might read something like:

“A person adept at solving technical problems in clever and delightful ways”

While the one portrayed by popular culture is what real hackers call “crackers”

“Someone who breaks into other people computers and causes havok on the Internet”

People who aspire to be hackers, like me, resent it when other people use the term in a demeaning and co-opted manner.  Or at least, that is what I used to think. For years, I have had a growing unease about the “split” between these two definitions. The original Hackers at the MIT AI lab did spend time breaking into computer resources… it is not an accident that the word has come to mean two things.. It is from observing e-patients, who I consider to be the hackers of the healthcare world, that I have come to understand a higher level definition that encompasses both of these terms.

Hacking is the act of using clever and delightful technical workarounds to reject the morality embedded default settings embedded in a given system.

This puts “Hacking” more on the footing with “Protesting”. This is why crackers give real Hackers a bad name. While crackers might technically be engaged in Hacking, they are doing so in a base and ethically bankrupt manner. Martin Luther King Jr. certainly deserves the moniker of “protester” and this is not made any less noble because Westboro Baptist Church members are labeled protesters too.

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