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Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?

Jun 28, 2011• 35

By KENT BOTTLES, MD

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act.Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.”

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.”

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care – particularly fictitious care – we’ve got a problem. Is this a new quality standard we can expect from our new government health care initiative? Just like scam-artists that phish for unsuspecting people’s financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud – plain and simple.”

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

Secret Shoppers: Needing A Weatherman To Know Which Way The Wind Blows

Jun 28, 2011• 1

By BRIAN KLEPPER

Every now and then, a well-intentioned administration does something relatively harmless but so hare-brained and openly foolish that it takes our breath away. The Obama Administration’s primary care “secret shopper” plan fit this bill, and has already been shelved due to the withering criticism. My inbox a couple days ago was filled with rants by physicians of all political persuasions marveling at the lameness of the idea.

Here’s a short description from Robert Pear’s article in Sunday’s New York Times.

The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

That primary care access has been squeezed is hardly in question. Undervalue a critically important resource, make it a financially undesirable choice for young professionalsand – Voila! – capacity drops. Having too few primary care physicians is the result of 20 years of systematic effort by the specialist-dominated American Medical Association, with the seeming oblivious complicity of both Democratic and Republican administrations.

Ironically, a new study answering a question related to the Administration’s project’s question was released last week. Writing in New England Journal of Medicine, Bisgaier and Rhodes had research assistants pose as mothers trying to make pediatric specialty care appointments, with type of insurance as the only variable. Two-thirds (66%) of those who mentioned Medicaid/CHIP were denied appointments, compared with 11% of those who mentioned private insurance. In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was 22.1 days longer, on average, than for those who said they had private insurance.

Are We Ready for Global Payments?

Jun 28, 2011• 2

By DAVID HARLOW

Massachusetts Attorney General Martha Coakley released her office’s second annual report, An Examination of Health Care Cost Trends and Drivers (PDF; see also press release), which contains a wealth of critical data analysis — and also highlights how little we know about certain things — providing some important context for the discussion of the proposed Part III of Massachusetts health reform, a bill filed by Governor Patrick which would create all-payor ACOs and a system of global payments.

At this late date, few would argue against a move a way from fee-for-service reimbursement for health care, or adding quality metrics to the mix, and tying financial rewards to providers to their performance measured against these metrics. (Consider the Massachusetts Blue Cross Blue Shield ACQ (alternative quality contract) experience.) The AG’s report, however, highlights the wide disparities in payments to providers based on negotiating strength, rather than quality or cost of care (as noted in last year’s AG report; check out the 2009 special commission report, too).

Sorrell vs. IMS Health: Not a Privacy Case

Jun 27, 2011

By JIM HARPER

The Supreme Court’s decision in Sorrell vs. IMS Health is being touted in many quarters as a privacy case, and a concerning one at that. Example: Senator Patrick Leahy (D-VT) released a statement saying “the Supreme Court has overturned a sensible Vermont law that sought to protect the privacy of the doctor-patient relationship.” That’s a stretch.

The Vermont law at issue restricted the sale, disclosure, and use of pharmacy records that revealed the prescribing practices of doctors if that information was to be used in marketing by pharmaceutical manufacturers. Under the law, prescription drug salespeople—”detailers” in industry parlance—could not access information about doctors’ prescribing to use in focusing their efforts. As the Court noted, the statute barred few other uses of this information.

It is a stretch to suggest that this is a privacy law, given the sharply limited scope of its “protections.” Rather, the law was intended to advance the state’s preferences in the area of drug prescribing, which skew toward generic drugs rather than name brands. The Court quoted the Vermont legislature itself, finding that the purpose of the law was to thwart “detailers, in particular those who promote brand-name drugs, convey[ing] messages that ‘are often in conflict with the goals of the state.’” Accordingly, the Court addressed the law as a content- and viewpoint-oriented regulation of speech which could not survive First Amendment scrutiny (something Cato and the Pacific Legal Foundation argued for in their joint brief.)

Why we need an independent health data utility

Jun 27, 2011• 19

By MATTHEW HOLT

This is another in the numerous “death of Google Health” stories that have been appearing since Friday when the Google blog announced the pulling of the plug. I must admit to being more than a little pissed off with Larry Page or whomever it was within Google that made the decision. After all, Google Health was only introduced a tad more than 3 years ago (premiered at HIMSS in Feb 2008; launched officially later that year). And just nine months ago they hired a new product manager and debuted some interesting new features connecting to the new wave of personal sensors. I know that Wall Street has been telling Google to focus on fewer products and that Page as new CEO has decided to do that but for a company as rich as Google the effort involved in keeping Google Health alive would be trivial. And props here to our friends at Microsoft who are integrating HealthVault into their wider health care business.

The sunsetting of Google Health has meant an outpouring of articles from the factual (Deb Linton at Health 2.0 News), to the historical (John Moore at Chilmark) to the winners/losers assessment (Fred Trotter) to the mega-quotes including mine (Marshall Kirkpatrick at ReadWriteWeb). There’s also been a steady stream of both sad and (sadly) happy people commenting on the Society for Participatory Medicine listserv, and Mr HISTalk was his cynical self–basically saying that tech know-nothings should stay out of our complicated health care business. He’s wrong and now Google is wrong, and here’s why.

With the very notable exception of HealthVault and (hopefully) some new innovation from Dossia, we are now dependent on a number of small companies to maintain the emerging data utility layer. The data utility layer in health is the place that is going to collectively store all the data that is being generated. Apparently Google didn’t have the real patience for two rapid developments.

First, with a combination of the Direct Project and the stipulation in the meaningful use regulations that EHR users share data with other providers and with patients, individuals are going to find that more and more data about themselves is available and easily accessible. Whether or not it’s a Farmville-type hit, the ability to capture all that information in one place is very important. Currently it’s also very time consuming to put together so very few people do it. But I do know of instances where people have laboriously entered lab values into Google Health just to store them. Sooner rather than later that data will be available much more easily in machine readable format, and as those barriers to use fall so the desire to look at that data will increase.

Google Health, can it be only mostly dead?

Jun 24, 2011• 1

So the rumors are true and Google Health is being sunsetted. I’ll have more to say about this soon, but as someone who has a lot of data in Google Health and who doesn’t really want to move it anywhere else–even though I don’t go in and look at it that often–I think that that answer might be to have some open source co-operative take it over. That was the original idea behind Dossia and there’s a budding open source community in health care that might be able to do something similar. In fact the biggest and most successful EMR (VISTA) was built by such a method (albeit within the VA). This is just a thought at the moment, but part of the issue is that we need to connect data from the health care system with data from the consumer device ecosystem without being beholden to either (especially the former). It is though ironic the Google Health is throwing in the towel when data liberacion, including the very successful Blue Button, and suggestions of open APIs from health care tech vendors, are just starting to come true. But perhaps there’s a way to get a Billy Crystal in the room and resurrect it from its planned end.

What About Personal Responsibility?

Jun 24, 2011• 76

By JOE FLOWER

A reader writes to ask: What about personal responsibility? “I see no movement afoot to require the public to accept or meet norms of behavior that would reduce the need for medical treatment—smoking, excess drinking, use of drugs, over weight, etc. What ever happened to ‘You reap what you sow’?”

Good question. I answered:

Thanks for writing. This is a common concern. It’s often expressed something like, “Why are we paying for all this healthcare for people who won’t take care of themselves?” This seems, at first blush, an obvious question with an obvious answer. After all, as I constantly point out in what you read, vast amounts of healthcare dollars are spent to correct what we might call “self-inflicted lifestyle damage.” Why should the rest of us pay for that? Where is the responsibility?

On inspection, the question is more complex and the answer is not so obvious. Let me try to parse it out. I can think of four related aspects of the question.

1. Their health affects ours. My wife and I had a lovely dinner at a very nice French restaurant on the waterfront here in Sausalito last night. The staff was all French, with those endearing accents. The busboy who set our table, poured the water, took away dirty plates and all that, was Mexican. I talked with him a bit in Spanish about the nice weather. I have no way of knowing his immigration status. Now, if I had my ‘druthers, just as a customer, would I rather that he have good access to healthcare and healthcare advice, be up on his flu vaccinations, be aware of the importance of washing his hands frequently, or would I rather he be a seething mass of communicable disease, compounded by ignorance?

Looking at Healthcare Through Payer Lenses

Jun 24, 2011• 11

By JOHN MOORE

Payers, as with the rest of the healthcare industry, have a lot on their plate right now. Healthcare reform, via the Affordable Care Act (ACA) continues its march forward despite legal and political uncertainty. Struggling to define the payer role in Accountable Care Organizations (ACOs), understanding the impact of Health Insurance Exchanges (HIXs) on their business (McKinsey survey results likely have many payers wondering how to market to what may be an enormous uptick in individual purchasers of coverage – something that most are ill-prepared for), and how to better engage consumers/members in proactively managing their health are a few of the top issues that were addressed at the AHIP Institute last week.

But when one sits back and reflects on the AHIP Institute – all of the sessions, all the discussions, the chatter in the halls, underlying messages within the message, the exhibit hall – it boils down to three key themes that this sector of the healthcare industry is grappling with, which much like the three stages of meaningful use, build upon one another:Continue reading…

Hacking Your Heart

Jun 23, 2011• 7

By ALEX EPSTEIN

implanted pacemaker xray

If they can hack your home computer, your mobile phone, apps, your store, your social networks, your bank account, your gaming system, your medical records, your school records, the government and its records, and pretty much anything anyone sets their mind to – isn’t it is only a matter of time until someone finds a way to hack your heart?

Not through a musical hook or melody that you can’t shake. Or a well timed smile by someone your soul connects with. Or a box of chocolates. Or a poem. People have been penetrating the human heart with those Luddite-ish tools since the beginning of civilization.

I was thinking more about that electronic device your doctor might have implanted into your chest to keep your heart beating. Or the little box stuck in your gut to help you and your pancreas regulate your diabetes. Or the mini-computer surgically inserted to keep your neurological systems on track.

Hacking the medical miracles put inside people to let them live longer with more normal lives.

While to my limited knowledge nobody has reported a single case and the likelihood is extremely low, it is a real enough concern that the New England Journal of Medicine published a paper about the need to improve security last year.

Twice Told Tale

Jun 23, 2011• 3

By PAUL LEVY

Back in 2008, Charlie Baker, then CEO of Harvard Pilgrim Health Care, and I, then head of a hospital, claimed that the market power displayed by the dominant provider system in the state and supported by the state’s largest insurer resulted in a large disparity in health care payments. We argued that this disparity contributed to unnecessarily high health care costs in the state. We both did this publicly, willing to put our assertions to the test. The quotes in response to this in a Boston Globe story were notable, but they did little to undercut our premises.

About a year later, the Attorney General of the Commonwealth published an investigation of this situation, which had the effect of validating our assertions.

Then, the largest insurer in the state said that the solution to the problem was to move towards a capitated, or global, payment regime. This would control the cost trend.

Again, knowledgeable observers, like the Inspector General, raised concerns. What if the global payment regime also created disparities and locked in higher rates? He noted, “[M]oving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.”

I pointed out that, while a global payment plan might have certain theoretical advantages, without a transparent exposition of its effects, how could we know if it had been successful?Continue reading…