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Hearts on Fire: a Tale of Two Californias

Sep 6, 2011• 1

By MATTHEW HOLT

The concept of practice variation raised its ugly head again this weekend in the northern California news media. And buried in the stories are several themes for our ages. But the conclusion is, the power of individual health systems and very small numbers of physicians to change patterns–and the cost–of care are enormous.

First the stories. Both about health care but also both revealing the future of investigative reporting. The BayCitizen is a non-profit blog about the San Francisco metro, created as response to the local papers cutting their reporting. It also provides stories to the NY Times–I’m unaware about how much of its revenue comes from the Times, but it’s part of the Times’ entry into non-NY competition with retreating local papers.

For this story on heart program readmission Katharine Mieszkowski picked up on an older UCSF press release and showed how UCSF used a $500K+ donation from the Gordon & Betty Moore Foundation (that’s the Moore of Intel & Moore’s law fame) to create a very sensible program that gave in-home support to newly discharged elderly cardiac patients. It cut readmission rates by 30%. The BayCitizen though will upset Gary Schwitzer as it did not include the actual numbers but the UCSF press release does, and yes this is a relative not an absolute cut. Here’s the key graf

Over the past 11 months, only 16 percent, on average, of the hospital’s heart failure patients were readmitted within a month of discharge, down from 23 percent in 2006. That’s well below the national 30-day readmission rate of 25 percent. The average readmission rate was 11.6 percent during the first four months of 2011.

So UCSF was about average and got much better and seems to be getting better still–but there’s quite a way to go. But it is an indication that at least one AMC is capable of moving the ball in the right direction. Of course UCSF is a leader in the pro-Dartmouth “use resources sensibly” camp, and we may or may not see the “keep em alive at all costs” folks at UCLA follow suit.

Meanwhile up in rural northern California it looks like the same Dartmouth data set is about to bring a series of visits from the FBI. Continue reading…

2011 Costs of Care Essay Contest

Sep 5, 2011

By NEEL SHAH

Do you have a story about a medical bill that was higher than you expected it to be? Or a time when you wanted to know how much a medical test or treatment might cost? How about a time you figured out a way to save money while still delivering high-value care?

As part of our second annual essay contest, Costs of Care, a nonprofit group based in Boston, is offering $4000 in prizes for anecdotes like these that illustrate the importance of cost-awareness in medicine. Judges will include former White House Budget Director Peter Orzsag, former United States Surgeon General C. Everett Koop, Governor Jennifer Granholm, women’s health and cancer research advocate Dr. Susan Love, and Harvard University Provost Dr. Alan Garber.

The mission of Costs of Care is to expand the national discourse on the role of care providers in controlling healthcare costs. The stories we receive as part of our second annual essay contest will provide everyday examples from across the nation that illustrate the power patients and healthcare workers have to curb costs at a grassroots level. Many of the submissions we receive will be published right here on The Health Care Blog.

Submissions should be no longer than 750 words and are due by November 15th. More details are available at www.CostsOfCare.org/essay. Email submissions to co*****@*********re.org.

You can also read about our winning essays from last year here.

Wendell Potter reveals Rick Perry’s ignorance

Sep 2, 2011• 3

What does a know-nothing Republican who doesn’t believe in science and is front-runner for his party’s nomination for President say about health care? Pretty much the same that the rest of them now do–unlike McCain, Huckabee et al in 2008. What’s the new Republican ideology? Apparently. there’s not much wrong with health care and what there is wrong, caps on malpractice payouts will fix. Perry cites the increase in the number of doctors in Texas since tort reform caps were put in as proof that it works. Wendell Potter at PR Watch shows that, when corrected with facts, everything Perry says is rubbish. But then again, were you surprised?

If You Get What You Pay For, How Much Should You Spend?

Sep 1, 2011• 36

By DAVID DRANOVE

I have been thinking lately about the state of the field of health services research. Having plied this trade for nearly 30 years, it struck me that many of the unanswered questions that I encountered as a doctoral student remain unanswered. I plan to post occasional blogs in which I pose these questions, discuss the state of the research, and explain why it is critical that we come up with better answers. The first question is really the big kahuna: If you get what you pay for, how much should you spend?

Everyone seems to agree that the U.S. spends too much money on healthcare. This has led many to embrace machete policies: Slash payments to doctors. Slash payments to hospitals. Slash payments to drug companies. Slash the number of specialists. Slash, slash, slash.

There is abundant research that past machete policies directed towards healthcare providers have adversely affect healthcare quality and access. There is also abundant evidence supporting the view that machete policies would curtail medical innovation. Medical providers and drug companies cite this evidence whenever they are threatened with payment cuts, proclaiming that any reductions from current levels would be disastrous for the American public.

The Need for a Level Playing Field for Physician Pay

Sep 1, 2011• 41

By PAUL FISCHER, MD

Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much. It’s part of the same ethic that teaches us not to criticize another doctor’s care.

But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest. If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?

History shows that physician pay rarely follows value, but rather aligns with power. When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own. Power and wealth followed.

About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT and MRI scans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.

The Wonks Are Wrong

Sep 1, 2011• 50

By RICHARD REECE, MD

I’ve heard critics express the idea a thousand times in a thousand ways.

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow. Patients aren’t listening.

They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem. Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care

Health 2.0: TweetChat and SF Agenda!

Sep 1, 2011

By Matthew Holt

The agenda for the Fall Health 2.0 Conference is up–and it is mega, as in by far the biggest thing we’ve ever done. Just getting the agenda right online took three of us all day!

Four Pre-Conferences. An overnight Code-a-thon and Health 2.0 101, educational session for developers and people new to health care. Two full days of main stage programming including more CEOs and tech whizes than you can imagine. Over 140 live product demos. More than 25 parallel sessions or Deep Dives. Live CEO interviews. And some “Unmentionable” topics never discussed at a health care tech conference before. Not to mention at least 20 brand new product introductions.

The conference is Sept 25-7 in San Francisco. The Exhibit Hall is sold out, the room block is going fast, registration is running well ahead of last year’s record crowd of 1,000, and ticket prices go up on Wednesday. Buy yours now, while they’re still available. Deals will be done, imaginations will be blown, history will be made. You won’t regret coming!

And just in case you need a little taster. From 9.30 PST/12.30 EST I’ll be running a 30 minute tweetchat tweeting from @boltyboy and @health2con. Just follow the #health2con hashtag —this Tweetchat link is a painless way to do that— and have fun with my questions and answers! See you there!

The ‘CSI Effect’ Hits Medicine

Aug 31, 2011• 21

By EVAN FALCHUK

I’m in Israel, home to some of the most innovative care in the world. Doctors here wanted to know if the high-tech tests that are an increasing part of their work help. A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis. As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued. But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S. American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study. According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S. Some call it the “CSI Effect,” after the TV show, CSI. In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty. Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis. They’re often surprised to see how it really works. Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis. Doctors often order high-tech tests because patients expect it.Continue reading…

Steve Jobs: Healthcare Revolutionary?

Aug 31, 2011• 2

By ALEX EPSTEIN

He killed the audio CD but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the world wide web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

Really? The practice of medicine?Continue reading…

Finding A Quality Doctor

Aug 30, 2011• 24

By DAVIS LIU, MD

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –

I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.Continue reading…