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Rob’s New Economics of Practice Management

• 20

By Rob Lamberts, MD

It has always been my assumption that my new practice will be as “digital” as possible. No, I am not going into urology, I am talking about computers. [Waiting for the chuckles to subside]

For at least ten years, I’ve used a digital EKG and spirometer that integrated with our medical record system, taking the data and storing it as meaningful numbers, not just pictures of squiggly lines (which is how EKG’s and spirometry reports appear to most folks). Since this has been obvious from the early EMR days, the interfaces between medical devices and EMR systems has been a given. I never considered any other way of doing these studies, and never considered using them without a robust interface.

Imagine my surprise when I was informed that my EMR manufacturer would charge me $750 to allow it’s system to interface with a device from their list of “approved devices.” Now, they do “discount” the second interface to $500, and then take a measly $250 for each additional device I want to integrate, so I guess I shouldn’t complain. Yet I couldn’t walk away from this news without feeling like I had been gouged.

Gouging is the practice of charging extra for someone for something they have no choice but to get. I need a lab interface, and the EMR vendor (not just mine, all of the major EMR vendors do it) charges an interface fee to the lab company, despite the fact that the interface has been done thousands of times and undoubtedly has a very well-worn implementation path. This one doesn’t hurt me personally, as it is the lab company (that faceless corporate entity) that must dole out the cash to a third-party to do business with me.

Doing construction in my office, I constantly worry about being gouged. When the original estimate of the cost of construction is again superseded because of an unforeseen problem with the ductwork, I am at the mercy of the builder. Fortunately, I think I found a construction company with integrity. Perhaps I am too ignorant to know I am being overcharged, but I would rather assume better of my builders (who I’ve grown to like).

Yet thinking about gouging ultimately brings me back to the whole purpose of what I am doing with my new practice, and what drove me away from the health care system everyone is so fond of. If there is anywhere in life where people get gouged or are in constant fear of gouging, it is in health care. Continue reading…

Replacing Lance

• 4

By JAMES SALWITZ, MD

We need heroes.  Heroes show us light in the darkness, the way to the miraculous and ignite a fire in our soul to survive.  They prove what is truly possible, through the fog of the impossible.  We mourn the disgrace of Lance Armstrong because he seems to have achieved Pyrrhic victory.  Let us not doubt; whatever his frailty as a man, Armstrong vanquished a terrible foe; moreover the path blazed is not bare, for everywhere are cancer heroes.

– The 45 year old RN raising her children while she works full time in a pediatric intensive care unit, celebrates her eighth year in remission from pancreatic cancer, treated with surgery, chemotherapy and radiation.

– The grandmother who ignored a breast mass for two years so she could care for four disabled grandchildren, and when the tumor grew to be massive, continues to take care of the children while receiving chemotherapy.

– The hospital chaplain who has suffered from cancer, sits at the bedside holding a hand, sharing a smile, saying a prayer that is heard deep in the heart and to the heavens above.

– The 71 year old with four different cancers, treated with a bewildering mix of surgery, radiation and chemotherapy, whose primary worry is the cardiac care of her husband.

– The 64 year old rescue squad volunteer while receiving chemotherapy and radiation for extensive lung cancer, assists 150 people to flee from their homes and escape the wrath of Sandy.

– The national lymphoma expert, who could be wealthy in his own clinic, instead devotes his life to teaching and research, believing he can save more lives by consulting and advising oncologists in communities around the country.

Continue reading…

Lawyers, Guns and Doctors

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By David Mokotoff, MD

Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality here.

First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies in Newtown, Ct. or Aurora, Co. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few other dangerous things I need to engage them with as well.

“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”

Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit bulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”

You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.

Continue reading…

About Time? Smokers Face Tough New Rules Under Obamacare

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By Dan Diamond

The Affordable Care Act contains a number of provisions intended to incent “personal responsibility,” or the notion that health care isn’t just a right — it’s an obligation. None of these measures is more prominent than the law’s individual mandate, designed to ensure that every American obtains health coverage or pays a fine for choosing to go uninsured.

But one provision that’s gotten much less attention — until recently — relates to smoking; specifically, the ACA allows payers to treat tobacco users very differently by opening the door to much higher premiums for this population.

That measure has some health policy analysts cheering, suggesting that higher premiums are necessary to raise revenue for the law and (hopefully) deter smokers’ bad habits. But other observers have warned that the ACA takes a heavy-handed stick to smokers who may be unhappily addicted to tobacco, rather than enticing them with a carrot to quit.

Under proposed rules, HHS would allow insurers to charge a smoker seeking health coverage in the individual market as much as 50% more in premiums than a non-smoker.

That difference in premiums may rapidly add up for smokers, given the expectation that Obamacare’s new medical-loss ratios already will lead to major cost hikes in the individual market. “For many people, in the years after the law, premiums aren’t just going to [go] up a little,” Peter Suderman predicts at Reason. “They’re going to rise a lot.”

Meanwhile, Ann Marie Marciarille, a law professor at the University of Missouri-Kansas City, adds that insurers have “considerable flexibility” in how to set up a potential surcharge for tobacco use. For example, insurers could apply a high surcharge for tobacco use in older smokers — perhaps several hundred dollars per month — further hitting a population that tends to be poorer.

Is this cost-shifting fair? The average American tends to think so.

Continue reading…

Are Healthcare and Health IT in a Dysfunctional Relationship?

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By Edmund Billings, MD

What a week last week! First the disgraced cyclist confession and later the baffling college-football-player-and-his nonexistent-(dead)-girlfriend story, with the RAND report sandwiched somewhere in between. It’s positively a scandal-palooza.

What’s that? You don’t feel like the recent RAND report, which basically says that a 2005 RAND study financed by GE and Cerner was wildly optimistic in predicting about $81 billion in potential health care cost savings through widespread adoption of electronic health records, qualifies as a genuine hoax, controversy, scandal?

Me neither.

But it does neatly frame what is arguably a unique characteristic of the healthcare industry—a trait that extends to peripheral industries as well. Basically, healthcare is an interconnected environment. Call it the systems theory of healthcare, co-dependency … or just regular dependency. Call it what you want, but there is an interconnectedness in healthcare that we ignore at the expense of national wellness.

Witness key data points provided by the RAND report:

  • Modern health IT systems are not interconnected and interoperable, functioning “less as ‘ATM cards,’ allowing a patient or provider to access needed health information anywhere at any time, than as ‘frequent flier cards’ intended to enforce brand loyalty…”
  • Neither are they widely adopted, with an estimated 27 percent of hospitals utilizing a basic electronic record. Without broad adoption, interoperability is far less relevant.
  • Improvements in quality of care / patient safety and reductions in healthcare costs (which have grown by $800 billion since 2005) are not manifesting with EHR adoption, in part because hospitals and clinics are rushing to adopt mediocre solutions and garner federal funds.
  • The provision of care is the same as it ever was, even though EHRs are frequently promoted as the optimal tool for a different kind of care.

The reasons for these disappointing stats are readily apparent and unalterably interconnected.
Continue reading…

Six Awkward Concerns in My OpenNotes

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By Leslie Kernisan, MD

I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.

Continue reading…

THCB Calendar: 2013 Harvard Business School Healthcare Conference

The 10th Annual Healthcare Conference at Harvard Business School is to be held Saturday, February 2, 2013. This year’s topic is Consumer-Centric Innovation.

Top 5 Reasons to Attend:

  • Network with over 700 students and professionals from Boston and beyond focused on healthcare
  • Hear from our keynotes: David Kirchhoff, President and CEO, Weight Watchers International; Nancy-Ann DeParle, Deputy Chief of Staff for Policy, Obama Administration; Kent Thiry, Chairman and CEO, DaVita Inc.; Tom Gentile, President and CEO, GE Healthcare Systems
  • Enjoy panel discussions across: pharma/ biotechnology, medical devices, diagnostics/ personalized medicine, healthcare financing, consumer health, payor/provider, IT, and emerging markets
  • Have a small group lunch with an industry leader of your choice
  • Attend our networking reception, with representatives from both established and emerging players

Please follow this link here to reserve your tickets. The current agenda and keynote speakers can be found at www.hbshealthcareconference.org

Open Health Data: An International Snapshot

By Eugene Borukhovich

The 2009 Digital Britain Report described data as ‘an innovation currency’ and ‘the lifeblood of the knowledge economy.’  We are now in 2013 and while there is tremendous buzz around open data in general, open health data is definitely lagging behind.

I have been a great proponent of the movement for a number of years after being inspired by Todd Park at a Health 2.0 NYC Chapter event. But it really clicked with me when I saw three young entrepreneurs mashup various environmental and health data, create an MVP app in 6 hours and win two prizes at an open data hackathon. These three students are on their way to starting a company and making a difference in this world while helping healthcare consumers make better decisions in their everyday lives. This is the power of open health data! We, the citizens, ultimately own the data, not our governments and while there is certainly a need to preserve our privacy, there is a lot of “innovation currency” locked up in vaults, desperately waiting to be unleashed.

Below, you will find a brief report (50 slides, but don’t get scared!) that Katarzyna Rabczuk and I put together.  It showcases how nascent this movement really is, while showing samples of social and economic impacts of these initiatives across the US, UK and a select few Western European countries picked at random.

The United States is undoubtedly leading the way with HealthData.gov and almost 400 valuable datasets published, ranging from Medicare data to epidemiology. Health Datapallooza is already turning 4 with the next event taking place in June of this year.

The United Kingdom is right behind (or ahead, depending which side of the pond you are on) with Tim Kelsey pushing forward and “unleashing the power of the people to save the NHS from a crisis”. The next NHS Hack day will take place on January 26th-27th in Oxford and some of the recent initiatives to open up prescription data generated a tremendous amount of buzz after a team that included two startups, Mastodon C & Open Healthcare UK as well as Ben Goldacre, published a report that showed how to save the NHS ~ £200M – this news reached even The Economist.

Continue reading…

And With the Stroke of a Pen, Health Insurance Exchanges Become Health Insurance Marketplaces ….

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By DAVID WILLIAMS

Thanks to David Kerrigan of the Massachusetts Health Connector for pointing out that the Obama Administration has suddenly switched terminology: health insurance exchanges are now health insurance marketplaces. I think it’s a great idea, which is why I wrote a blog post on this very topic on Friday. The Hill (Obama officials ditch ‘exchanges’ in rebranding of healthcare reform law) covers the story.

However, the Hill has a weird angle on this. The article heavily features an anti-ObamaCare activist, Dean Clancy who says:

“They could call them motherhood or apple pie, but it wouldn’t change our feelings about them… We’re encouraged that they’re showing signs of desperation. I think that it’s too late in the game to try to start calling this something different. And [we’re] not going to spend a lot of effort fighting over a word.”

Clancy’s website is called blockexchanges.com, so he may actually have more commitment to the word exchange than the Obama folks. Somehow blockmarketplaces.com just doesn’t have the same ring to it. (That domain is still available at this writing in case you want to grab it.) Blockexchanges also has some misleading information on its home page:

“Remember, without the state exchanges, ObamaCare cannot function.”

Actually, the federal government will step in if the states don’t.

Personally, I don’t sense desperation but rather a gradual wising up about what implementation will require. The term “marketplace” makes a good deal of sense for someone who is comparison shopping for health insurance. Here’s to more commonsense improvements as ObamaCare is rolled out.

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.

Why Employers Should Stop Worrying About Health Costs

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By Leah Binder

A report published by the Institute of Medicine (IOM) on high-value health care attracted attention when it was issued last June. Authored by a group of eleven leading hospital executives, A CEO Checklist for High-Value Health Care describes programs at various hospitals that resulted in quality improvements and lowered costs. The report has a section called “Yield,” quantifying the extent of these improvements. These programs sound notable, and in fact I know some of the executives and hospitals involved, and would vouch that many significantly improved patient care.

But the report is less impressive when it tackles the cost side of the value equation, especially when it names cost control outcomes like: “days cash on hand increased from 180 to 202,” and “multiple years of 4-5 percent [hospital] margin.” Clearly, the hospitals improved their own bottom lines, but by how much did patient bills decrease? The hospital executives don’t account for that in the “yield.”

It seems this report defines “high-value” to mean highly valuable to hospital CEOs. Strikingly, though, the authors do not find it necessary to explicitly say so anywhere within the report. Perhaps they simply assume that a high-value checklist for hospital CEOs is automatically high-value to CEOs in other industries that are paying for services from hospitals. No offense to these well-meaning and highly accomplished hospital executives, but that is not always the case. Purchasers don’t see high-value health care in hospital cash flow or profit margins. They see value when they get the best service at the best price.

Continue reading…

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