The Health Care Blog – Page 608 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Rational Rationing vs. Irrational Rationing

Sep 13, 2012• 27

By David Katz, MD

Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

Health Care’s Man on the Moon Moment?

Sep 12, 2012• 7

By Peter Pronovost, MD

On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.

Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.

So we set out to change this. We developed a program that included a checklist of best practices, an intervention called CUSP [the Comprehensive Unit-based Safety Program] to help change culture and engage frontline clinicians, and performance measures so we could be accountable for results. It worked. We virtually eliminated these infections.

Then in 2003 through 2005, with funding from AHRQ, we partnered with the Michigan Health & Hospital Association. Within six months in over 100 ICUs, these infections were reduced by 66 percent. Over 65 percent of ICUs went one year without an infection; 25 percent went two years. The results were sustained, and the program saved lives and money, all from a $500,000 investment by AHRQ for two years.

My Open Source Cure

Sep 12, 2012

By Lia Steakley

[youtube width=”475″ height=”300″]http://www.youtube.com/watch?v=5ESWiBYdiN0[/youtube]

TED Fellow Salvatore Iaconesi released this video along with his digital medical records – everything from CT and MRI scans to lab notes. He posted the health files to invite the online world to participate in the process of treating his brain cancer. As he wrote on his website:

This is my OPEN SOURCE CURE. This is an open invitation to take part in the CURE. CURE, in different cultures, means different things. There are cures for the body, for spirit, for communication.

Grab the information about my disease, if you want, and give me a CURE: create a video, an artwork, a map, a text, a poem, a game, or try to find a solution for my health problem. Artists, designers, hackers, scientists, doctors, photographers, videomakers, musicians, writers. Anyone can give me a CURE.

Create your CURE using the content which you find in the DATI/DATA section here on this site… All CURES will be displayed here.

Continue reading…

Obama vs. Romney: A Detailed Analysis of Mitt Romney’s Health Care Reform Plan

Sep 11, 2012• 16

By Robert Laszewski

Let’s take a look at Mitt Romney’s Health Care plan using his own outline (“Mitt’s Plan”) on his website.

Romney’s approach to health care reform summarized:

“Kill Obamacare” – There seems to be no chance Romney would try to fix the Affordable Care Act––he would repeal all of it.
No new federal health insurance reform law – There is no indication from his policy outline that he would try to replace the health care reform law for those under age-65 (“Obamacare”) with a new federal law–his emphasis would be on making it easier for the states to tackle the issue as he did in Massachusetts.
Small incremental steps – His approach for health insurance reform for those under age-65 relies on relatively small incremental market ideas when compared to the Democrats big Affordable Care Act–tort reform, association purchasing pools, insurance portability, more information technology, greater tax deductibility of insurance, purchasing insurance across state lines, more HSA flexibility.
Getting the federal government out of the Medicaid program – He would fundamentally change Medicaid by putting the states entirely in control of it and capping the annual federal contribution–“block-granting.”
Big changes for Medicare – Romney offers a fundamental reform for Medicare beginning for those who retire in ten years by creating a more robust private Medicare market and giving seniors a defined contribution premium support to pay for it.

It’s the Patient, Stupid

Sep 10, 2012• 13

By ANIL SETHI

Electronic health records (EHRs) offer many valuable benefits for patient safety, but it becomes apparent that the effective application of healthcare informatics creates problems and unintended consequences. As many turn their attention to solving the seemingly intractable problems of healthcare IT, one element remains particularly challenging–integration–healthcare’s “killer app.” Painfully missing are low-cost, easy to implement, plug-and-play, nonintrusive integration solutions. But why is this?

First, we must stop confusing application integration with information integration. Our goal must be to communicate data (ie, integrate information), not to integrate application functionality via complex and expensive application program interfaces (APIs). Communicating data simply requires a loosely coupled flow of data, as occurs today via email. In contrast, integration is a CIOs nightmare. Integrating applications, when we just wanted a bit of information, is akin to killing a gnat with a brick.

Even worse, like a bad version of Groundhog Day, the healthcare IT industry keeps repeating the same mistakes, and we keep working with these mistakes. Consultants and vendors from whom we request simple data communication solutions offer their sleight of hand, which usually recasts our problem into a profitable application integration project that simply costs us more money. This misdirection takes us down a maze of tightly coupled integrations that are costly, fragile and brittle, and not really based on loosely-coupled data exchanges, a simpler approach that allows the Internet to perform so well.

The key to unlocking the potential of EHRs lies in securely communicating (a.k.a. exchanging) data between EHR silos. If we simply begin by streaming data from EHR systems onto a common backbone, using a common currency like XML (eXtensible Markup Language), we will have solved healthcare integration in a way that works the way much of the Internet works. And this is good. When this happens, we know interoperability will work, robustly.Continue reading…

Dropping Out

Sep 8, 2012• 111

By ROB LAMBERTS, MD

After 18 years in private practice, many good, some not, I am making a very big change. I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job. The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve. The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk. I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

I don’t feel like I can offer the level of care I want for my patients. I am far too busy during the day to slow down and give people the time they deserve. I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
There’s a disconnect between my business and my mission. I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed). But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone. I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient. Why is it that I would make more money if I was a bad doctor? Why am I penalized for caring?
The increased burden of non-patient issues added to the already difficult situation. I have to comply with E/M coding for all of my notes. I have to comply with “Meaningful Use” criteria for my EMR. I have to practice defensive medicine to avoid lawsuits. I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all. My previous post about burn-out was a prelude to this one; it was time to do something about my burn out: to drop out.Continue reading…

Healthcare Reform’s Missing Link — Nurse Practitioners

Sep 8, 2012• 44

By Patricia Dennehy, RN

Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.

It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.

Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.

Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.

Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.

Breaking News: Health Information Technology Sucks and it Costs too Much

Sep 7, 2012• 57

By Dave Chase

“Established technology is being given a federally funded new lease on life,” athenahealth CEO Jonathan Bush said. “Traditional health software now is on Medicare, being kept alive like grandma.” Bush dubs this program as the “cash for clunkers” program for health IT leaving no doubt what his opinion is regarding the legacy vendors’ solutions.

“I know of no industry where technology is as despised as it is in health care. It’s a statement that it took government money to incentivize healthcare providers to finally do what virtually every other industry has done .”

While one might dismiss Bush’s comments because they are coming from a company with a dog in the fight, the feeling is nearly universal amongst physicians who are the most important users. The best evidence of how abysmal legacy healthIT is, is that the market leader is having trouble getting medical practices to adopt their software even with huge subsidies from large health systems.

In the course of discussions with large health systems, they share their experiences of deployments of a mega Electronic Medical Record (EMR) and how they were offering subsidies to affiliated doctors to adopt the same system. When pressed about how broadly it was being adopted by non-employee physicians (i.e., MDs who have a choice), the penetration was staggeringly low — 0.2% was the average of those who shared figures. This was despite the fact that they were subsidizing 85% of the cost (the maximum allowed by Stark Law).

When I’ve spoken with doctors who have rejected the entreaties from their affiliated health systems, it’s more than the expense (even after a massive subsidy, it’s still several thousand dollars plus monthly costs). Rather, the complexity and lack of user friendliness is the bigger driver. A common statement one hears in healthIT conversations is that doctors hate technology or are afraid of it. Hogwash. They only hate bad technology. Consider the iPad. Doctors are the biggest buyers and it’s not just young doctors.

Flawed Reimbursement Model Leads to Flawed HealthIT

This begs the question, “why is healthIT so bad that massive government and health system subsidies are required to drive adoption?” And how can this possibly be good news? Let me address the issues and then I’ll conclude with the good news. While it may seem easy to bash legacy healthIT vendors, my experience has been that vendors reflect their customers. I would take this a step further. In the case of healthcare, customers reflect the reimbursement model. It’s a reimbursement model that is so broken Americans pay nearly twice as much as other countries to get inferior outcomes.

The Internet’s Downsides: Tell Us Your Stories

Sep 6, 2012• 10

By Susannah Fox

This is a request for help finding people who have had bad experiences with online health resources.

Let me first say that the internet is often a positive force in people’s lives.

My own organization’s research can paint a rather rosy picture: teens are mostly kind to each other online, technology users have more friends than those who stay offline, more people are online than ever before, etc.

But there is another side to the story.

Pew Internet has also documented the fact that, among other groups, people living with disability and those living with chronic health conditions are disproportionately offline. Some people have only dial-up or intermittent access, like at the library or a friend’s house, and therefore miss out on important conversations or information.

The internet can also transmit false or misleading information. A 2010 survey found that 3% of all U.S. adults said they or someone they know has been harmed by following medical advice or health information found online (1% minor, 1% moderate, and 1% serious harm). Thirty percent of adults reported being helped.

There are emotional pitfalls online, too. A 2006 Pew Internet survey found that 10% of people seeking health information online said they felt frightened by the serious or graphic nature of what they found online during their last search.

Are Hospital Business Models on a Burning Platform? Not Yet, But It’s Inevitable.

Sep 6, 2012• 8

By Vince Kuraitis

From reading recent headlines, one might easily get the impression that hospitals are resistant — or at least ambivalent — in their pursuit and adoption of accountable care initiatives.

Are Hospitals Dragging their Feet on Accountable Care?

Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”

KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”

Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”

The Bigger Picture

Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative?

The answer from the headlines above might suggest “no”, but I believe the correct answer is “not yet, but it’s inevitable”. Hospitals are feeling the heat, but it’s just not yet hot enough to jump off the platform and abandon existing business models.