[viddler id=dc40e5a8&w=560&h=270]
Matthew Holt sat down with McKesson at the World Health Care Congress 2012. Medical Director of McKesson Health Solutions Douglas Moeller, MD and McKesson VP of Enterprise Architecture and Technology Bob Franceschini explained what they’re doing to keep up with evolving payment methods.
In its wisdom, the Supreme Court of the United States may decide to overturn the Obama administration’s health reform legislation.
The Supreme Court of the United States may decide not to.
Mitt Romney may unseat Barrack Obama and wrest the Presidency away from the Democrats. Or he may not.
In a way, these things may not actually matter.
There may be uncertainty on Wall Street and in the media about the fate of the Affordable Care Act (ACA) and the upcoming presidential election, but the mood in the crowd gathered at the 9th session of the World Health Care Congress last week in Washington was curiously upbeat.
There was a sense that health care is making progress.
And that is a good thing.
Innovations like accountable care organizations (ACOs), scientific management principles like cost containment and quality improvement and the movement for better health information technology will make their presence felt, regardless of what happens in the courts and on Election Day.
Unlike TEDMED, which brought together official Washington, the tech industry, entertainment and medicine — at the Kennedy Center last week, the World Health Care Congress is a meeting pretty much limited to health care industry insiders at larger firms.
As is generally the case, the speakers list read like a who’s who of very important healthcare names. Kaiser Permanente CEO George Halvorson, Intermountain CEO Charles Sorensen, Aetna CEO Mark Bertolini, Economists Ezekiel Emanuel and Jonathan Gruber, former OMB Director Peter Orzag, TEDMED curator (Priceline.com) Jay Walker talked about the power of the Internet to fundamentally rewire the way people think. Verizon CEO and NantWorks Founder Patrick Soon-Shiong were on hand to talk up a new collaboration. Xerox CEO Ursula Barnes introed the tech giant’s push into healthcare. Journos like Health Affairs Editor Susan Dentzer and NBC correspondent Nancy Snyderman provided media star power.
It all began when Dr. Renee Hsia of the University of California at San Francisco received a simple request from a good friend who had checked into a local hospital for an emergency appendectomy. The fairly routine procedure took place 19,368 times during 2009 in California.
After he returned home, he received a bill from the hospital for $19,000, his co-payment for the parts of the $54,000 operation that his insurance company didn’t cover. “He wanted to know if this was the usual and customary charge for a one-day stay in the hospital,” she recalled.
And thus began her research into pricing variability in the state, which was published this week in the Archives of Internal Medicine. The prices ranged from $1,529 to $182,955 with the median hospital charge of $33,611, the study showed.
The prices not only varied between hospitals, they varied within hospitals. The largest spread occurred at one hospital, which Hsia wouldn’t reveal, where the cheapest appendectomy went for $7,504 while the most expensive charged was $171,696. There were numerous hospitals where the spread was $100,000 or more.
“They had the same diagnosis, but different things could have been done,” she said. For instance, one patient could have had multiple imaging tests and robotic laparoscopy, while the other received no imaging and a regular laparoscopy. There’s no evidence to suggest one set of alternatives had better outcomes than the other.
On April 17th, 81-year-old Warren Buffett told investors that he had very early prostate cancer. The Washington Post headline read: “Warren Buffett Has Prostate Cancer that is Not Remotely Life Threatening.’” Within hours, news accounts said that the story unfolded after discovering a high PSA in a routine appointment. Next, he had a prostate biopsy. A few hours later, news accounts said that Buffett decided to get radiation therapy for prostate cancer. What’s wrong with this picture?
10. He’s an icon who other men will follow, and there is limited (or no) evidence of benefit of aggressive treatment in men as old as Buffett. At 81, his life expectancy is 7.41 years, shy of the 10-year life expectancy mark doctors look for when they recommend aggressive treatment for prostate cancer.
9. Although Buffett can afford whatever care he so desires, it would cost a fortune if tons of men in his age group went for active treatment and there would be little yield and plenty of side effects.
Last week I found my usually-diverse Twitter feed had coalesced into a single hashtag, the trolley buses chugging through the streets of Washington, D.C. were sporting bold logos on their sides, and all around the city people were wearing giant nametags bearing their name, face, and three things they liked to talk about. There was no mistaking it: TEDMED was in town.
For the world of health care, TEDMED was the only party at which to see and be seen. The thousand or so delegates had been specifically “curated” to encapsulate the epitome of health care innovation. For 3.5 days they basked in cutting-edge, quirky talks by people “shaping and creating the future of health and medicine,” punctuated by lavish dinners and parties, TEDMED-themed M&Ms, and morning runs, as sanctioned by the Cookie Monster (one of the celebrity speakers at this extravaganza). Meanwhile, the rest of the medical world followed the #TEDMED hashtag on Twitter or soaked up the inspiration in real time at one of TEDMED’s mostly academic simulcast venues around the U.S.
And as for me? I threw myself into getting invited to the cool kids’ party. Or to be more accurate, the cool, privileged kids’ party. Because as well as being accepted on merit, attending TEDMED in person costs an eye-watering $4,950. A wealth of sponsors paid for 200 people to attend on scholarships (and for the Simulcasts), but by the time I’d realized this and persuaded them of my innovative brilliance, they’d already allocated their funds and I was consigned to their priority waiting list. But at the last minute, delightfully, my persistence and anticipation were rewarded with a pass for the Thursday night party and the final Friday morning session.
On the eve of the release of this year’s Medicare Trustees report, the Obama administration released its own version of it. In the administration’s telling:
But whereas the Trustees report is expected to be a serious document, reflecting accepted accounting principles, the administration’s document was clearly a piece of political propaganda — one that stretched the truth so much that the word “spin” would be a charitable description. For example, the administration’s document failed to mention that:
Recently a patient with advanced lung cancer was admitted to a local hospital. Pain in his abdomen was diagnosed as a gallbladder infection.
Because he had metastatic cancer, in addition to the new problem, the patient and family decided that if things deteriorated he should not be given CPR or put on a respirator. A Do Not Resuscitate (DNR) order was entered in his chart. Treatment for the gallbladder was continued, but it was decided that there was a line that the doctors would not cross.
This made sense to me.
Try conventional therapy, but if he was too weak to recover, then do not continue treatment which could cause more suffering than benefit. Give him the opportunity to survive the gallbladder problem, but respect the terminal nature of the greater disease. We were all gratified when his pain and fever went away, and he recovered from the emergency.
When we were discharging him from the hospital, a surprising thing occurred.
The patient and family requested that since he had survived the infection, that the DNR be reversed. They decided that when a sudden new major medical complication occurred, that CPR be performed and he would be placed on a respirator. The clear protective line vanished.
In difficult lengthy discussions with the patient and family, it became clear that they were riding tides of emotion. When things looked better, they focused on life and “cure.” When things grew worse, they were ready to withdraw. They became defensive and angry at the suggestion that this decision might cause suffering. We were not able to redefine limits to his care.
The New York Times and other media outlets are trumpeting a new GAO report that blasts an ongoing $8 billion Medicare demonstration project. CMS has put the money towards a new pay-for-performance scheme for Medicare Advantage plans. The media have focused their attention on part of the GAO study describing how most of the money will go to average performing plans (those receiving as few as three “stars” out of a possible five), with 90 percent of plans receiving some sort of bonus.
If that were the gist of the GAO complaint, then the GAO would have been the ones guilty of wasting taxpayer money for writing a useless report. But the key elements of the GAO report pertain to a different matter: will the demonstration allow CMS to determine whether the new pay-for-performance scheme is superior to the existing scheme? Here the GAO report gets bogged down in the details of research methodology. The media understandably got lost in this discussion and have given this part of the report short shrift. As a result, I expect politicians to blast CMS for “giving $8 billion to bad health plans” and other stuff of nonsense.
Let me explain why it is pointless to focus on how the money is distributed among Medicare Advantage plans. The purpose of any pay-for-performance scheme is to provide incentives for improving quality. (A scheme that rewards the best plans but does nothing to alter the status quo really is a waste of money.) Some of the comments by the GAO and aped by the media would have you believe that the best way to improve quality is to reward the top achievers. Tell this to parents of a D student who would be grateful to see their child get C’s. Should they tell their child “we will take you on a nice vacation but only if you get all A’s?” Talk about killing motivation.
I believe the Health 2.0 community can put to rest any concerns that patient engagement will be difficult by commenting below on how apps they’ve built or seen can help blow away the requirements proposed in Stage 2 Meaningful Use.
In an earlier piece, I asked the question “Will the ONC provide a huge stimulus to Health 2.0 startups?” I touched on how this could be the biggest boost the health 2.0 startup community has ever received. Elsewhere, there has been pushback such as an article in Healthcare Informatics that describes patient engagement as The Least Popular Thing About Stage 2 MU So Far. In particular, providers question the requirement that 10 percent of patients access their data.
I don’t doubt that the proposed requirements will be difficult for some but I hope we aren’t, once again, beset by the tyranny of low expectations. 10% is a strikingly low # when you consider that health items are the 3rd most searched items across the entire population (not just sick people who should be much more motivated on a relative basis). While we know that some people are difficult to engage, it’s a llllonggggg way from 90%.
It’s only difficult (today) because the incentive systems have created a dynamic where providers have become highly skilled at getting as big a bill out as fast as possible. Why wouldn’t they have developed that skill? That is exactly what the flawed “do more, bill more” model of reimbursement has rewarded. The byproduct is they haven’t honed their skills at engaging patients. Having worked with hundreds of providers and dozens of vendors, these are smart and motivated people. I have ZERO doubt that they will rise to the expectations if they are given the chance.
What does it take to get into medical school today?
High MCAT scores. Pre-requisites galore, coupled with a stellar GPA. Research experience. Clinical experience. Volunteering.
It has become a series of check-boxes, many going through the process gripe. Worse, it’s an exercise in conformity.
Last week at TEDMED, Dr. Jacob Scott shone the spotlight on this system as a root cause of the lack of creativity among people going into medicine.
“You can’t take any risks, or you won’t get in [to medical school] – you won’t get into the club,” he told the audience. But, he continued, that means weeding out creativity. Future doctors are being trained to “memorize certainty,” rather than think imaginatively.
Having gone through the admissions process recently, I could relate to many of Dr. Scott’s sentiments. It’s true: preparing to get into medical school does little to encourage risk-taking. Admission criteria are rigid. And you know if you don’t do what they ask, there is no shortage of others who will.
Want to become a doctor? You can’t slip up, or you’ll fall behind. You can’t rock the boat, or you won’t get admitted.
This critique is not unique to medical education. Scott’s talk reminded me of a speech by former Yale English professor William Deresiewicz to the 2009 plebe class of the United States Military Academy at West Point. Skeptical of modern benchmarks of success, Deresiewicz told the young cadets:
“It’s an endless series of hoops that you have to jump through [to get into college], starting from way back… What I saw around me were great kids who had been trained to be world-class hoop jumpers. Any goal you set them, they could achieve. Any test you gave them, they could pass with flying colors…. I had no doubt that they would continue to jump through hoops and ace tests and go on to Harvard Business School, or Michigan Law School, or Johns Hopkins Medical School, or Goldman Sachs, or McKinsey consulting, or whatever. And this approach would indeed take them far in life.”
THCB's Podcasts
Listen to them on Itunes or Spotify
