The Health Care Blog – Page 612 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

All Hell Hath Broken Loose

Aug 21, 2012• 46

By Robert Laszewski

I’ve never seen a week in health care policy like last week. The media reports have to be in the thousands, all trying to make sense of the furious debate between Obama and Romney over Medicare.

As someone who has studied this issue for more than 20 years, it has also been more than exasperating for me to watch each side trade claims and for the press to try to make sense of it.

This blog post is quite long because the subject matter is complicated. If you want to cut to the chase, see my conclusion and summary at the end of this post.

Allow me to list a few of the questions people are asking and give you my take on it.

Will current seniors suffer under the Romney-Ryan Medicare plan?

No. Let me start by saying something that will likely surprise you. If I could be king for a day, I would prohibit anyone over the age of 60 from voting in this election. This election is really about the future and the big decisions on the table are about the long-term government spending and entitlement issues that should be made by younger voters who will have to pay for them and will benefit or suffer from them.

Those in their 60s and older are almost surely going to cruise to the end with the benefits they now have.

Whether its Obama’s Medicare plan, based heavily on the Medicare cost control board imbedded in his health reform bill (which doesn’t begin to impact hospital costs until 2020), or the Romney/Ryan Medicare premium support plan (that has no effect on anyone now over the age of 55), today’s seniors’ benefits are insulated from this issue.

The Age Rating Game: Will Older Americans Pay More Under Health Reform?

Aug 20, 2012• 107

By Maggie Mahar

The Affordable Care Act leaves it to the states to decide whether they want to let insurers charge older Americans more for coverage. If a state takes no action, a 64-year-old buying his own insurance in the individual market will pay up to three times more than an 18-year-old. In the small-group market – if a small business employs an unusually large number of older workers – the same 3:1 ratio applies.

Today, in most states, there are no caps on how much insurers can charge a 60-something forced to purchase his own insurance. In the individual market, only New York State bans age rating altogether, and just three other states limit how much premiums can vary, based on age, to less than 3:1. When insurers sell policies to small businesses, Vermont also prohibits age rating, but only five other states cap increases.

To check whether your state shields older boomers in either of these markets, take a look at these charts. (A checkmark in the right-hand column means that age rating is now unregulated in that state.)

Help from the younger generation?

10 Ways to Make the EMR Meaningful and Useful

Aug 20, 2012• 27

By Rob Lamberts, MD

I am an EMR geek who isn’t so thrilled with the direction of EMR. So what, I have been asked, would make EMR something that is really meaningful? What would be the things that would truly help, and not just make more hoops for me to jump through? A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list:

Require all visits to have a simple summary.
One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes. I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit. Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
Allow coding gibberish to be hidden.
Related to #1 would be the ability to hide as much “fluff” in notes as possible. I only care about the review of systems and a repetition of past histories 1 out of 100 times. Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter. The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed. It is only input into the note for billing purposes.

Continue reading…

Profits, Quality, and U.S. Hospitals

Aug 20, 2012• 8

By Ashish Jha, MD

The recent articles in the New York Times about the Hospital Corporation of America (HCA) have once again raised important questions about the role of for-profit hospitals in the U.S. healthcare system. For-profits make up about 20% of all hospitals and many of them are part of large chains (such as HCA). Critics of for-profit hospitals have argued that these institutions sacrifice good patient care in their search for better financial returns. Supporters argue that there is little evidence that their behavior differs substantially from non-profit institutions or that their care is meaningfully worse.

To me, this is essentially an empirical question. Yet, I read the through the articles, I was struck by the dearth of data provided on the quality of care at these hospitals. Based on the comments that followed the stories, it was clear that many readers came away thinking that these hospitals had sacrificed quality in order to maximize profits. Here, I thought an ounce of evidence might be helpful.

Measuring quality:

There is no perfect way to measure the quality of a hospital. However, the science of quality measurement has made huge progress over the past decade. There is increasing consensus around a set of metrics, many of which are now publicly reported by the government and even are part of pay-for-performance schemes. While one can criticize every one of these metrics as imperfect, taken together, they paint a relatively good, broad picture of the quality of care in an institution. We focused on five metrics with widespread acceptance:

Who Owns Patient Data?

Aug 20, 2012• 34

By Fred Trotter

Who owns a patient’s health information?

·The patient to whom it refers?
·The health provider that created it?
·The IT specialist who has the greatest control over it?

The notion of ownership is inadequate for health information. For instance, no one has an absolute right to destroy health information. But we all understand what it means to own an automobile: You can drive the car you own into a tree or into the ocean if you want to. No one has the legal right to do things like that to a “master copy” of health information.

All of the groups above have a complex series of rights and responsibilities relating to health information that should never be trivialized into ownership.

Raising the question of ownership at all is a hash argument. What is a hash argument? Here’s how Julian Sanchez describes it:

Why the Electronic Medical Record Needs to be Viewed as a Medical Device

Aug 20, 2012• 20

By WESTBY FISHER, MD

In our rush to establish a national electronic medical record (EMR) system as part of the American Recovery and Reinvestment Act of 2009, powerful silos of independent EMR systems have sprung up nationwide.

While most systems are being developed responsibly, like the Wild, Wild West, many have been developed without an objective eye toward quality and the potential harm they may be causing our patients.

As most readers of this blog are aware, since 2005 the medical device industry in which I work has had widely publicized instances of patient deaths splashed all over the New York Times and other mainstream media outlets from defibrillator malfunctions that resulted in a just a few patient deaths.

The backlash in response to these deaths was significant: device registries were developed, software improvements to devices created, and billions of dollars in legal fees and damages paid to patients and their families on the path to improvement. In addition, we also learned about the limits of corporate responsibility for these deaths thanks to legal precedent established by the Reigel vs. Medtronic case.

Why We Avoid Telling Patients the Truth

Aug 18, 2012• 18

By STANLEY WINOKUR, MD

When I started practicing oncology, I was frequently asked by my patients, “What’s my prognosis, what can I expect?” At first, I was reluctant to tell the patient very much, especially when I knew the prognosis wasn’t good. I wanted to spare the patient the details of the inevitable outcome of his cancer, so I downplayed the truth. Some may call it sugarcoating the information. I just wanted to do anything I could to protect my patient from learning that not only didn’t we have a cure for his cancer, we didn’t even have a treatment to extend his life. The best we could do was to maybe improve the quality of his life for as long as possible.

Now, years later, not much has changed. Today, most patients with cancer never receive information from their physicians about their prognosis or even imminent death. According to a recent article in The Journal of the American Medical Association, not telling patients their prognosis leads to a worse quality of life for both patients and their caregivers.

Why are physicians so reluctant to give their patients truthful answers regarding their prognosis? When asked, most oncologists say that they don’t want to take away their patients’ hope of recovery. Others say they are afraid that if they tell them the truth, the patients will stop treatment. Some worry that their patients will leave and seek the advice of another physician.

All American Physicians Should Be Members of the AMA

Aug 18, 2012

By George Lundberg, MD

All American physicians should be members of the American Medical Association (AMA). And, while they are at it, they should also be members of their county, state, and principal specialty societies.

Why? Because they are the only games in town, and both security and safety are top Maslow imperatives.

The only real political power any physician has is the individual power of persuasion and participation (or not) and the power of a group.

American physicians, if united, would have huge clout, speaking with one voice. American physicians, divided as now, speak with hundreds of thousands of individual voices, a cacophony of futility.

As The Bard saith in Macbeth “… tales told by idiots, full of sound and fury, signifying nothing.”

If you are an American physician and you don’t like what the AMA has done and is doing, if you are not a member, shut your mouth, you have no right to complain.

The Way Out of the Wilderness

Aug 17, 2012• 37

By David Dranove

In 1932, the Committee on the Cost of Medical Care identified rising medical costs as a threat to the financial security of millions of Americans. In a series of studies that created the field of health services research, the Committee recommended several strategies for cost containment that reads like a blueprint for today’s cost containment efforts: prevention, price controls, capitation, elimination of unnecessary care, and integration. If it sounds like a précis of my previous two blogs – cut prices and cut quantities – it should. We have known for a long time that those are the only ways to cut spending. And yet here we are, 80 years later, facing a spending crisis that threatens to take down the entire economy.

In my lifetime, we have been subjected to a steady drumbeat of rising medical costs. There have been respites – for a couple of years after Medicare introduced DRGs and for about five years in the 1990s during the heyday of HMOs. While DRGs and HMOs shifted costs down, they did not seem to reverse underlying growth trends, although HMOs did not thrive for long enough to be certain.

Not for lack of trying have medical costs continued to increase. We promote prevention, regulate prices, capitate providers, and review utilization to eliminate wasteful spending. We have seen horizontal integration that led to market power and higher costs, and vertical integration that more often than not created unmanageable bureaucracies. Most of today’s proposals for cost containment can be encapsulated by two words: “Try harder.” The Affordable Care Act gives us free preventive care, stricter price controls, ACOs, and the Comparative Effectiveness Institute. We need radical change but all we get is creeping incrementalism. I will take creeping incrementalism over the do-nothing approach of the previous decade, if only because we could use another respite. But the ACA is no permanent fix.

To Gauge Hospital Quality, Patients Deserve More Outcome Measures

Aug 17, 2012• 13

By PETER PRONOVOST, MD

Patients, providers and the public have much to celebrate. Recently, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

The addition of bloodstream infections data is a huge step forward. These potentially lethal complications, measured using Centers for Disease Control and Prevention’s methods, are among the most accurately measured outcomes. In addition, the science of how to significantly reduce these infections is mature, and hundreds of hospitals of all types and sizes have nearly eliminated them. A program to reduce these infections that started at Johns Hopkins Hospital was spread throughout Michigan, and is now being implemented throughout the U.S., demonstrating substantial reductions.