The Health Care Blog – Page 560 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Into the Extrapolation Machine

May 12, 2013• 3

By Les Funtleyder

The Kaiser Family Foundation (KFF) recently released a study that showed that 42% of Americans are unaware that Obamacare (the Affordable Care Act) remains the “law of the land.” News like this seems to us, to act as a Rorschach test on how observers feel about the law. Considering 50% of Americans can’t identify New York on a map we tend not to read too much into these polls. However, according to the logic of extrapolation, since we know that the ACA remains law, we are in the elite 58% (it’s about time we made it into the elite of something).

In almost parallel to the KFF news, the New England Journal of Medicine published a follow-up study of the “Oregon experiment.” For those who haven’t been following closely, the study found that previously uninsured people who were enrolled in Medicaid did not see an improvement in clinical measures when compared to those who remained uninsured. The study did seem to show a reduction in the amount of financial distress for the insured however.

Another contentious study, another Rorschach test (example, example). The problem we see with the polarity of views is that both sides seem to be cranking up the extrapolation machine and use single studies/data points to draw broad conclusions to gin up opinions about ACA’s success or lack thereof. In light of the fact that for most practical matters ACA doesn’t really get going until 2014, use of the extrapolation noise generator approach smacks of a lack of analytical rigor in our view. We will know soon enough how the program is doing… exchanges start enrolling on 10/1.

As investors, we should state upfront that we tend to give more weight to financial returns than what the philosopher-kings might call the political context. So what caught our eye in the Oregon study was that Medicaid recipients had higher healthcare utilization rates (and associated costs) than the uninsured. The connection between gaining insured status and healthcare utilization should not come as a surprise since there is a very extensive literature elucidating this connection.

The Bounce Back Effect

May 12, 2013• 5

By Anubhav Kaul, MD and Sindhu Kubenderan

Critically ill Medicare patients, who are battling for stable health at the end of life, are victims of repeated hospitalizations, especially after being discharged to a skilled nursing facility (SNF). The cycle of hospitalizations is an indicator of poor care coordination and discharge planning – causing the patient to get sicker after every “bounce back” to the hospital. Total spending for SNF care was approximately $31 billion in 2011; with an estimated one in four patients being re-hospitalized within thirty days of discharge to a SNF.[1]

Each readmission leads to further test and treatments, higher health care costs, and most importantly, patient suffering. It is hard to imagine that patients would prefer to spend their last few months of life shuttling from one healthcare setting to another and receiving aggressive interventions that have little benefit to their quality and longevity of life. The heroic potential of medical care should not compromise the patient’s opportunity to die with dignity. A hospital is not a place to die.

Medicare beneficiaries are eligible to receive post-acute care at SNFs, after a three day hospital admission stay. SNFs provide skilled services such as post-medical or post-surgical rehabilitation, wound care, intravenous medication and necessities that support basic activities of daily living. Medicare Part A covers the cost of SNF services for a maximum of 100 days, with a co-payment of $148/day assessed to the patient after the 20^thday. If a patient stops receiving skilled care for more than 30 days, then a new three day hospital stay is required to qualify for the allotted SNF care days that remain on the original 100 day benefit. However, if the patient stops receiving care for at least 60 days in a row, then the patient is eligible for a new 100 day benefit period after the required three day hospital admission.[1] It is evident that the eligibility for the Medicare SNF benefit is dependent on hospitalizations – many of which may be a formality and a source of unnecessary costs.

The Bedside Manifesto

May 11, 2013• 2

By Jeff Kane, MD

“Most of us went into medicine because we love spending time with patients,” said Johns Hopkins Hospital’s Leonard Feldman, MD.

Dr. Feldman is co-author of an article published April 18 in the Journal of General Internal Medicine which reveals that medical interns spend only 12% of their time examining and talking with patients, and more than 40% of their time on computer tasks.

“Our systems have squeezed [patient contact] out of medical training,” said Dr. Feldman.“ All of us think that interns spend too much time behind the computer. It’s not an easy problem to solve.”

For three weeks a year ago, investigators observed 29 interns at two Johns Hopkins University internal medicine residency programs for a total of 873 hours. Direct patient care accounted for only 12.3% of interns’ time, and computer use for 40%. The paucity of direct interaction may explain previous studies’ findings that only 10% of hospitalized patients know which resident physicians are responsible for their care. “I think we can do better,” said Dr. Feldman.

He’s right. Unless we want healthcare to devolve ultimately into a system of vending machines, we need to restore its traditional personal intimacy. But medical sages have been chanting that mantra since the 1920s. What holds it up?
Continue reading…

The Problem-Oriented Medical Record

May 10, 2013• 10

By Leslie Kernisan, MD

[This post is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.

The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.

Specifically, the Weeds make the following points:

Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.

Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.

For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.

Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”

Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.

In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.

The Rest of the Story About Hospital Pricing

May 9, 2013• 30

By David Dranove

The recent Medicare report on variation in hospital “prices” is not exactly news. In fact, I wonder why anyone (including the NY Times and NPR) covered it, let alone make it a lead story.

As you probably know, Medicare reported that hospital charges for specific treatments, such as joint replacement surgery, greatly vary from one hospital to another. (This includes charges for all services during the hospitalization, including room charges, drugs, tests, therapy visits, etc.) Everyone in the healthcare business knows that charges do not equal the actual prices paid to hospitals, no more than automobile sticker prices equal the prices that car buyers actually pay. Except that for the past thirty years, the gap for hospitals greatly exceeds (in percentage terms) the gap for cars. This is not just a nonstory, it is an old nonstory.

So reporters tried to give it a new spin. One angle concerns the uninsured, who may have to pay full charges. I will write about this in a future blog. Another angle is that by publishing these charges, Medicare will encourage patients to shop around. That is the subject of this blog.

I suppose it is okay to tell patients that the amount they might have to pay out of their own pockets may vary from one hospital to the next. But the published charge data is useless for computing out of pocket payments; in fact, it may be worse than useless. As even the NY Times noted, insured patients make copayments based on prices that their insurers negotiate with hospitals. These prices are essentially uncorrelated with charges. So a patient who visits a hospital with low charges may well make higher out-of-pocket payments than a patient who visits a high charge hospital. It is a crap shoot.

No Resident Left Behind

May 9, 2013• 2

By Shirie Leng, MD

Yesterday at the faculty meeting, we learned that the first year residents in anesthesia will now have to take AND PASS a written exam at the end of their first year. They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way. Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year. You didn’t have to pass it or get a certain grade; it was sort of a reality check, to see how you were doing. I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test. It might be a solution in search of a problem, I have no idea.

Here’s the thing. Testing freaks residents out. They have been taking high-stakes tests their whole entire lives. In high school they had to get As and score a 1400 on the SAT. In college they still had to get As, but also had to ace the MCAT. In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t. Results of those had bearing on what residency you got into. The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test. Residents are masters of this. There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online. Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.

Validating Mrs. X

May 9, 2013• 1

By Ali Ansary

Mrs. X is a 46 year-old mother of two and wife to an Iraq war veteran. On this particular day she meets with her oncologist to follow up after treatment for skin cancer. Beyond her well-groomed hair, thick plastic framed glasses and coral-red manicured toes, she doesn’t have a clear agenda for her appointment and expectations have only been vaguely outlined. However, this will change.

Wired Magazine asked Mucca Design in 2010 to reimagine the blood test report and the result was an inspiring new way of communicating with patient. 2011 marked the launch of the Tricoder X-Prize worth $10 million supported by X-Prize Foundation and Qualcomm. The goal is to bring to life the fictional Star Trek multifunctional handheld medical device that can scan, analyze and produce results with a goal to diagnose patients better than or equal to a panel of board certified physicians. And while 2012 launched a series of new medical innovations that leverage the power of the mobile device, 2013 will be a time to bring together these technologies into a web of interconnectedness.

In 2013, Mrs. X and her mobile device will have access to a digital medical record that gives access to prior appointment notes, recorded videos from remote mobile appointments with her team of physicians, and yesterday’s blood work results. New innovations in medicine will create a foundation for Mrs. X to have better access to care, translate her behavior into actionable data all being tied together to provide what is most important: validation.

How to Avoid Being a Chump For CEOs

May 9, 2013• 24

By Leah Binder

A trio of groundbreaking publications on healthcare came out this April. They are my required reading list for CEOs. First is a study published in last week’s Journal of the American Medical Association (JAMA) by Eappen and colleagues (including among them Atul Gawande). The study found infections occurred in 5 percent of all surgeries in an unnamed southern hospital system. For U.S. hospitals, this is not an unusual rate of error — even though it is about 100 times higher than what most manufacturing plants would tolerate. No automaker would stay in business if 5 percent of their cars had a potentially fatal mechanical flaw.

If that’s not bad enough, the second finding is where we enter the realm of the absurd: according to the study, purchasers paid the hospital to make these errors. Medicare paid a bonus of more than $3000 for each one of the infections; Medicaid got a relative “bargain,” paying only $900 per infection. But the real chumps were the commercial purchasers (CEOs, that’s you). Employers and other purchasers paid $39,000 for each infection, twelve times as much as your government paid through Medicare. Most companies could create a good job with $39,000, but instead they paid a hospital for the privilege of infecting an employee. How many good jobs haven’t been created so businesses can pay for this waste?

Most employers are far more hard-nosed about managing their purchase of, say, office supplies than they are in purchasing health care — even though, unlike healthcare, paperclips never killed anyone and no stapler can singlehandedly sap a company’s quarterly profit margin. Yet, according to the Catalyst for Payment Reform, only about 11 percent of dollars purchasers paid to healthcare providers are tied in any way to quality. The results reflect this neglect of fundamental business principles for purchasing: Quality and safety problems remain rampant and unabated in health care, while employer health costs have doubled in a decade. Continue reading…

A Duty to Share Patient Information

May 8, 2013• 4

By Vince Kuraitis and Leslie Kelly Hall

The sharing of patient information in the US is out of whack — we lean far too much toward hoarding information vs. sharing it. While care providers have an explicit duty to protect patient confidentiality and privacy, two things are missing:

the explicit recognition of a corollary duty to share patient information with other providers when doing so is the patient’s interests, and
a recognition that there is potential tension between the duty to protect patient confidentiality/privacy and the duty to share — with minimal guidance on how to resolve the tension.

In this essay we’ll discuss:

1. A recent recognition in the UK

2. The need for an explicit duty to share patient information in the US

Open Data Advocate Joins Patient Privacy Rights Group as Chief Technology Officer

May 7, 2013• 8

By Adrian Gropper, MD

The small news is that I formally joined Patient Privacy Rights as chief technology officer. I have been an extreme advocate for open data for years. For example, I’m a card-carrying member of the Personal Genome Project where I volunteer to post both my genome and most of my medical record. PPR, on the other hand, is well known for publicizing the harms of personal data releases. These two seemingly contradictory perspectives represent the matter-antimatter pair that can power the long march to health reform.

The value of personal medical data is what drives the world of healthcare and the key to health reform. The World Economic Forum says: “Personal data is becoming a new economic “asset class”, a valuable resource for the 21st century that will touch all aspects of society.” This “asset” is sought and cherished by institutions of all sorts. Massive health care organizations, research universities, pharmaceutical companies, and both state and federal regulators are eager to accumulate as much personal medical data as they can get and to invest their asset for maximum financial return. Are patient privacy rights just sand in the gears of progress?