The Health Care Blog – Page 614 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Here’s a Question to Ask Romney or Ryan

Aug 15, 2012

By Aaron Carroll, MD

Last week, I noted the significant differences between Paul Ryan’s proposals, from his 2012 budget to Ryan-Wyden to his 2013 budget. I also noted that while it would be tempting to campaign against the 2012 budget, which massively shifted costs onto seniors, his later proposals did that to a far lesser extent.

Or did they?

Governor Romney has endorsed Paul Ryan’s latest plan, which is specific in that it will reduce future Medicare spending by unleashing the power of the free market through competitive bidding. But what if that doesn’t happen? Well, just like the ACA, his law backstops the growth of Medicare spending at GDP + 0.5%.

The ACA is explicit about what will happens if growth goes above that amount. The IPAB will make recommendations on how to cut it. Congress will have to override those recommendations to stop them, and have their own ideas that save just as much. It’s likely those recommendations would involve reducing provider payments. But it’s the hope of those who support the ACA that other provider-based changes, like ACO’s and the excise tax, will keep the IPAB from having to act.

Do You Believe Doctors Are Systems, My Friends?

Aug 15, 2012• 24

By David Shaywitz, MD

In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.

The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).

The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.

According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.

Hospital Rankings Get Serious

Aug 15, 2012• 4

By Ashish Jha, MD

After years of breaking down, my sedan recently died. Finding myself in the market for a new car, I did what most Americans would do – went to the web. Reading reviews and checking rankings, it quickly became clear that each website emphasized something different: Some valued fuel-efficiency and reliability, while others made safety the primary concern. Others clearly put a premium on style and performance. It was enough to make my head spin, until I stopped to consider: What really mattered to me? I decided that safety and reliability were my primary concerns and how fun a car was to drive was an important, if somewhat distant, third consideration.

For years, many of us have complained about the lack of similarly accessible, reliable information about healthcare. These issues are particularly salient when we consider hospital care. Despite a long-standing belief that all hospitals are the same, the truth is startlingly different: where you go has a profound impact on whether you live or die, whether you are harmed or not. There is an urgent need for better information, especially as consumers spend more money out of pocket on healthcare. Until recently, this type of transparent, consumer-focused information simply didn’t exist.

Over the past couple of months, things have begun to change. Three major organizations recently released groundbreaking hospital rankings. The Leapfrog Group, a well-respected organization focused on promoting safer hospital care, assigned hospitals grades (“A” through “F”) based on how well it cared for patients without harming them*.

What Healthcare Must Learn — from a Chain Restaurant

Aug 14, 2012• 1

By Joe Flower

In Healthcare Beyond Reform: Doing it Right For Half The Cost I lay out the five strategies that healthcare must adopt, and is adopting in various ways and places, to make healthcare better and cheaper at the same time.

Strategy Five is “Rebuild Every Process.” It’s about “lean manufacturing,” smart standardization, measurement, “big data,” evidence-based design, teaching the innovation, all the detailed, rigorous, hard attention to intelligent process re-design that healthcare is so obviously lacking — and that is absolutely necessary if healthcare is to improve its abysmal cost/benefit ratio.

Now in The New Yorker writer/surgeon Atul Gawande has done a brilliant turn on this theme, by diving into, of all things, the processes of a restaurant chain, comparing them to the duplicative, chaotic, mistake-prone processes of traditional healthcare, and finally to some examples of smart, rebuilt healthcare processes that drive down costs while killing fewer people.

Gawande shows how The Cheesecake Factory manages to deliver 308 dinner menu items and 124 beverage choices to exacting standards, on time, from fresh ingredients, with only 2.5% wastage, in a linen-napkin and silverware environment, at lower cost, then compares that with the disconnected, uncoordinated, messy environment that is most of US healthcare. He details several examples of how new drives toward standardization and control of processes in the operating room and the emergency department, for instance, are making a difference, lowering costs and improving not only outcomes but the patient experience, all at the same time.

The Health Care Handbook

Aug 14, 2012

MARKETPLACE

The American health care system is vast, complex and confusing. Books about it shouldn’t be. The Health Care Handbook is your one-stop guide to the people, organizations and industries that make up the U.S. health care system, and the major issues the system faces today. The Handbook’s five chapters cover:

· Inpatient and outpatient health care and delivery systems
· The different types of health insurance and how they’re structured
· A clear summary of the Affordable Care Act, the Supreme Court decision, and other reform options.
· Concise summaries of 31 different health professions
· Medical research, technology, and drugs
· Health policy and government health care programs
· Economic concepts and the factors that make health care so expensive
· The Pharmaceutical and Medical Device industries

Closing the Translational Gap: A Challenge Facing Innovators in Medical Science — and in Digital Health

Aug 14, 2012• 1

By David Shaywitz, MD

The gap between model or potential solutions and solutions that work in the real world – the translational gap — is arguably the greatest challenge we have in healthcare, and is something seen in both medical science and in digital health.

Translational Gap in Medical Science

The single most important lesson I learned from my many years as a bench scientist was how fragile most data are, whether presented by a colleague at lab meeting or (especially) if published by a leading academic in a high-profile journal. It was not uncommon to watch colleagues spend months or even years trying to build upon an exciting reported finding, only to eventually discover the underlying result was not reproducible.

This turns out to be a problem not only for other university researchers, but also for industry scientists who are trying to translate promising scientific findings into actual treatments for patients; obviously, if the underlying science doesn’t hold up, there isn’t anything to translate. Innovative analyses by John Ioannidis, now at Stanford, and more recently by scientists from Bayer and Amgen, have highlighted the surprisingly prevalence of this problem.

See One, Do One, Harm One?

Aug 14, 2012• 28

By Peter Pronovost, MD

I recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

The Weight of the Nation

Aug 14, 2012• 1

By Kristin Molven

Kristin Molven is a medical student at The University of Olso. She is currently a student in the Norwegian Entrepreneurship Programme at UiO and UC Berkeley, and is interning at Health 2.0.

HBO’s documentary series The Weight of the Nation made me sad. I was left with the feeling that the wealth my parents have provided and all prior generations’ good intentions to make it easier for us to gather food and survive, and the technologies they developed to make our lives easier now are destroying us. My generation is short-circuiting. When looking to satisfy our needs, we meet no obstacles, no resistance. Everything is readily available to us, and we are fast-forwarding towards the negative consequences of constant access. And the food industry makes a profit off our misfortune.

The Weight of the Nation campaign consists of four main films, a dozen of extra short films and an accompanying book and website. It was launched in May by HBO and the Institute of Medicine in association with the Centers for Disease Control and Prevention, the National Institutes of Health, Michael & Susan Dell Foundation and Kaiser Permanente.

The campaign abandons the idea that obesity is an individual shortcoming or to results from a lack of self-control. Instead the campaign holds society responsible for today’s weight problems. Come to think of it, this is not unreasonable as humans have the same mental capabilities as former generations that were not obese. What has changed is our behavior and surroundings. Physical activity has been engineered out of our daily routine, while unhealthy tempting food has become cheaper and more accessible. Let’s not pretend that our grandparents had higher moral standards by avoiding sugar and fat and took the stairs instead of the elevator. They surely would have made the same choices as us if they had the chance. Given that nobody intends to become overweight or obese, we have designed a society where it is just too hard for most of us to maintain a healthy weight.

Consequences and Choices, the two first films of The Weight of the Nation series, examine the physiology and pathology of weight gain and obesity.Continue reading…

Why We Won’t See EHR Consolidation Anytime Soon

Aug 13, 2012• 1

By John Moore

All too frequently I get the question:

When will we see the EHR market consolidate?

Not an unreasonable question considering just how many EHRs there are in the market today (north of 300) and all the buzz regarding growth in health IT adoption. There was even a recent post postulating that major EHR consolidation was “on the verge.” Even I have wondered at times why we have not seen any significant consolidation to date as there truly are far more vendors than this market can reasonably support.

But when we talk about EHR consolidation, let’s make sure we are all talking about the same thing. In the acute care market, significant consolidation has already occurred. Those companies that did not participate in consolidating this market (Cerner, Epic & Meditech) seem to have faired well. Those that pursued a roll-up, acquisition strategy (Allscripts, GE, McKesson) have had more mixed results.

It is the ambulatory sector where one finds a multitude of vendors all vying for a piece of the market and it is this market that has not seen any significant consolidation to date and likely will not see such for several years to come for two dominant reasons.

Bad Directions

Aug 13, 2012• 11

By Rob Lamberts, MD

I love the GPS analogy for health care. Patients need a GPS for their health, showing them the reality of their past, present, and future health. The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.

Way back in the days when GPS was new, the rental care company Hertz advertised “NeverLost,” a GPS on your dashboard (if you forked out the extra money for it). I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill). While I found it overall very useful, there were a couple of times it didn’t work as advertised.

I needed a sweatshirt, so I used the NeverLost for directions to a Wal-Mart. It worked! It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away). I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.
Then, when I was trying to get to Crater Lake, “Never Lost” repeatedly directed me down dirt roads, some of which had trees fallen across their path. NeverLost was quite perturbed when I didn’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.