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Above the Fold

There’s No Choice but Change

Jun 14, 2011• 52

By GRACE-MARIE TURNER

The outrageous distortions about the Ryan Medicare reform plan are coming from people who are accelerating the program’s path to insolvency.

Medicare is being used as a piggy bank by Democrats, with $575 billion in payment cuts used to finance two massive new entitlement programs in Obamacare. And this April, the president proposed taking another $480 billion out of the program to lower the deficit.

Payments to providers will be cut so deeply that seniors will find it harder and harder to get care. Doctors will stop taking Medicare or go bankrupt. A whopping 87 percent of doctors say they will stop seeing or will restrict the number of Medicare patients they see, further shrinking the pool of providers and further restricting access to care.

The powerful, 15-member Independent Payment Advisory Board will use price controls to meet ever-elusive spending targets. Rationing is inevitable, especially of newer medicines and technologies.

House Energy and Commerce chairman Fred Upton explained, “Last year, Medicare expenditures reached $523 billion, but the income was only $486 billion — leaving a $37 billion deficit in just one year. And with 10,000 new individuals becoming eligible each day, it’s only going to get worse.”

Medicare is $38 trillion in the red, and it accelerated five years toward insolvency in just the last year, according to the Medicare Trustees’ latest report.

A Look Back – 30 Years Later – At The Impact Of AIDS On Residency Training

Jun 14, 2011• 2

By BOB WACHTER, MD

Last week marked the 30th anniversary of the first reports of a cluster of cases of pneumocystis pneumonia in gay men in Los Angeles. While I’ve recently heard a number of reflections on these early years, I’ll focus on a topic that I haven’t seen covered: how AIDS transformed training – including my own – and what the emergence of AIDS taught me about innovation and, yes, opportunism.

In early 1982, I was a 3rd year student at Penn on my first medicine ward rotation. One night, my team admitted a young gay man with a bizarre story: progressive wasting, spiking fevers, profound dyspnea, and diffuse infiltrates on his chest x-ray. The next morning, I presented the case to my attending, David Goldmann. Having just read reports of a similar illness galloping through urban gay communities, at the end of my presentation David said gravely, “This thing” – the disease didn’t yet have a name – “is changing the way we practice medicine.”

When I arrived at UCSF in 1983 to begin my internal medicine residency, it didn’t cross my mind that this decision would guarantee that my training would be dominated by this new scourge. In 1985, as a third year resident, I jotted down some of my reflections in an essay. It began:

Like many of today’s interns and residents training in San Francisco, New York, and Los Angeles, I have cared for many more patients with Pneumocystis carinii pneumonia than pneumococcal pneumonia, more patients with Kaposi’s sarcoma than breast cancer, and more patients with cryptocococcal meninigitis than meningococcal meningitis… This realization has prompted me to consider the impact of AIDS on medical residency training.

I sent this paper, entitled “The Impact of AIDS on Medical Residency Training,” off to the New England Journal of Medicine. Of course, this was a naïve and hubristic thing for a resident to do, but I really didn’t know any better. A few weeks later, while on the wards at the VA, I received a page for an outside call. “Hi, this is Dr. Marcia Angell,” said the voice on the other end. “I’m an editor at the New England Journal. We really liked your article but we’ll need a few changes before we publish it.”

The Stunning Shift Toward Employed Physicians

Jun 14, 2011• 85

By DAVID E. WILLIAMS

I’m amazed at just how quickly physician employment has swung from small independent practices to hospital-based employment. I’ve heard about it anecdotally from medical societies and malpractice carriers who are seeing their constituents shift, and have certainly observed the shift from individual physicians, but I’m still surprised how fast it’s occurring. A new report from recruiter Merritt Hawkins tells the clearest story I’ve seen:

In the last 12 months, 56% of physician search assignments have been for hospital jobs, whereas 5 years ago it was just 23%
Just 2% of assignments were for independent, solo practice docs compared with 17% 5 years ago

Doctors are becoming more like regular wage earners, albeit high paid ones. There are some strong drivers of this trend including the need to support health information technology, comply with regulations and deal with health plans. There’s also a desire on the part of a younger, increasingly female physician workforce to have a better balance between work and home life. If anything the forces pulling physicians into hospital employment will strengthen in the near term with the arrival of Accountable Care Organizations and other forms of deep integration.

Yet when a pendulum swings it tends to swing too far. Especially considering how quickly things have moved, I do expect that there will be some backlash to the rush into employment. It’s really not all that much fun having a boss, especially when that boss is a big, bureaucratic hospital with other things on its priority list besides MD satisfaction and career development. Patients may not like it so much either. I know I’d rather see a physician who’s not too tightly tied to a hospital.

So what will the reversal look like? I don’t think it’s going to be doctors rushing to put up their own shingles or buy practices of retiring docs like in the old days. Instead I expect to see a new breed of physician employers who recognize what’s needed to make docs happy, treat patients well, manage compliance, and still make money. One example is so-called direct primary care practices such as Qliance. Time will tell what other forms develop.

Getting to the Heart of the Industry Transformation

Jun 14, 2011• 1

By CHAD HARRIS

Documents are heart of the healthcare industry – providers rely on them to provide critical, up-to-date and real-time information on a patient’s health and care. It makes sense, then, that documents are the central figure in the radical transformation the industry is in the middle of. It’s critical that an organization have a system in place to manage documents with pinpoint precision and efficiency, yet document inefficiency continues to be an enormous cost driver and cause of errors.

Providers have a lot on their plates – develop a system that works best for their organizations, physicians and patients, and that also meets meaningful use guidelines and deadlines. It’s not a one size fits all. Overhauling the patient record system can be a long journey, and requires the careful selection of appropriate systems, proper implementation, and the understanding and cooperation of staff members. It can be daunting in that organizations understand just how important it is to get it right.

Botsford Hospital is an example of an organization that understands how much is on the line in implementing an electronic medical record (EMR) system. The 330-bed hospital located in Farmington Hills, Mich., is less than a year away from a fully operational EMR, and put a lot of thought and effort into the decision-making process, including these steps:

Evaluated existing processes to make them more efficient and effective before moving to an EMR.
Established an Office of Clinical Process Improvement along with a steering committee to guide the process and develop objectives for a new EMR system.
Engaged ACS, A Xerox Company, a long-time IT services partner, to assist in the selection of an EMR solution.
Involved employees in the decision-making process by asking for routine input from the nurses, physicians and IT staff.

Botsford chose the McKesson Paragon solution, an all-inclusive and fully-integrated hospital information system, and is currently entering the final phases of implementation, which includes integrated testing and end-user training. The hospital is on track to meet its financial and productivity goals with this endeavor.

Project ECHO: A Game-Changer for Patient Care?

Jun 14, 2011• 7

By BRIAN QUINN

I met Sanjeev Arora as part of the RWJ crowd at TEDMED last year and was pretty impressed with his approach–especially given the lack of access to care in poor and minority regions. Now there’s proof his approach works —Matthew Holt

On June 1 the New England Journal of Medicine published a study about how primary care providers can treat very sick patients who previously did not have access to specialty care. The piece described Project ECHO, a disruptive model of health care delivery based on collaborative practice that has the potential to transform health care. Supported by Robert Wood Johnson’s Pioneer Portfolio and based at the University of New Mexico Health Sciences Center (UNMHSC), Project ECHO was developed by Sanjeev Arora, M.D., a hepatologist at UNMHSC and leading social innovator.

The ECHO model organizes community-based primary care clinicians into disease-specific knowledge networks that meet through weekly videoconferencing to present patient cases. These “virtual grand rounds” are led by specialists at academic medical centers who train providers to provide specialized care, share best practices and co-manage complex chronic illness care for patients with the local care team. Under this model, primary care providers treat patients in their own communities – burdens on academic center capacity are reduced, poor access to care is eliminated (patients are no longer limited by geography when seeking quality care), and the health care systems’ capacity to provide high quality care to more patients, sooner, is dramatically expanded.

In the NEJM study, patients with hepatitis C treated by primary care clinicians working through Project ECHO achieved results that were identical to patients treated by UNMHSC specialists. The evaluation also showed that the ECHO model can reduce racial and ethnic disparities in treatment outcomes.

Lost in the Mckinsey mire

Jun 13, 2011• 1

It’s a good week for Bob Kocher, a key architect of the ACA, to be leaving Mckinsey and moving into the word of venture capital. There’s lots of fuss in wonkdom about whether Mckinsey’s survey of employers was statistically correct and peer reviewed or more of a push poll. There’s lots of fuss even apparently within the firm about the validity of the estimate that 30% of employers (or is it employees) will be moved over to the exchanges. But despite ballyhoo over the Mckinsey report, because in 2009 the White House got stuck into the mantra that “if you like your insurance you can keep it” the fact that it’s good to get employers out of providing health insurance has been missed. If you have insurance from an employer that puts you in the exchange it’s a fair bet that your coverage was anyway going to move to levels worse than that mandated by the government. And the levels of coverage and behavior of the plans in the exchange which will hopefully actually be enforced–with the threat of being booted out being a motivator. And as we all know employers are the worst purchasers of health care out there and need to be got out of the game. That was what the very sensible Wyden-Bennet plan did, but as the collective stupidity of the nation’s unions and chambers of commerce is very high, we ended up with the ACA instead. Oh well, welcome to America.

Prospecting for Gold

Jun 13, 2011

By JANE SARASOHN-KAHN

3 in 4 of the Fortune 50 companies are part of the U.S. health economy in some way. Only 1 in 3 of these is in traditional health industries like pharmaceutical and life science companies, insurance, and businesses in the Old School Health Care value chain.

2 in 3 of the Fortune 50 companies involved in health are in new-new segments. In their report, The New Gold Rush, PricewaterhouseCoopers (PwC) identifies four roles for “prospectors” in the new health economy which will represent 20% of the GDP by 2019:

Fixers
Connectors
Retailers, and
Implementers.

These are the disruptive roles that will be played by new, non-traditional entrants seeking their piece of the health care economy.

Jane’s Hot Points: This week marks the second annual Health Care Innovation Week in metro Washington, DC. Each day held a different meeting addressing some aspect of disruptions in health care. Today marks the second annual Health Care Data Initiative meeting, to be held at the National Institutes of Health in Bethesda, MD, where I will participate in a health data-palooza organized by the Health 2.0 Conference.

“Connectors” will play an all-important role today and in the new-new health economy. PwC says that Connectors succeed “by linking information and technology across the health system. They provide meaningful analysis and context so that clinicians and consumers can make better decisions about health behaviors.”

As physicians and providers continue to adopt electronic health records, and use them more deeply and smartly, consumers will be doing the same in their world via USB-connected blood pressure devices, digital glucometers for managing diabetes, WiFi weight scales, and a score of mobile health apps to track real-life, personal data. Without interoperability and connectivity between these siloed applications, the “gold” can’t be mined. Providers won’t optimize clinical decisions at the point of care, and consumers won’t be empowered to stay as well as they could or manage chronic conditions as effectively as they would in a data-liquid health world.

Jane Sarasohn-Kahn is a health economist and management consultant that serves clients at the intersection of health and technology. Jane’s lens on health is best-defined by the World Health Organization: health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. She blogs regularly at HEALTHPopuli.

Economists Gone Wild

Jun 13, 2011• 5

By PAUL LEVY

Economists are so embedded in their training with the concept of ceteris paribus — “all other things held equal” — that their policy prescriptions often go awry. Here are two recent examples:

First, in the March 10, 2011 issue of the New England Journal of Medicine, David Cutler and Leemore Dafney argue against transparency of pricing in the health care sector.

The rationale for price transparency is compelling. Without it, how can consumers choose the most efficient providers of care? But though textbook economics argues for access to meaningful information, it does not argue for access to all information. In particular, the wrong kind of transparency could actually harm patients, rather than help them.

Applying the sunshine rule in the provider–payer context, however, could have the opposite of the intended effect: it could actually raise prices charged to patients.

[T]he sunshine policy would create a perverse incentive for the hospital to raise prices (on average), and as a result its rivals could do the same. This adverse effect of price transparency would arise only in cases in which the buyer or supplier in question had some leverage (market power), but such leverage is fairly common in health care settings, including many local hospital markets.

What’s the flaw here? In markets like Eastern Massachusetts, there is a dominant provider which uses its market power to garner above average prices from the insurance companies in its service area. That provider, in turn, can use those revenues to offer higher salaries than its competitors, drawing doctors into its orbit. It also has more resources to expand its ambulatory care facilities. Both steps serve to further expand its market power.

Analyzing A Crucial Battle In The Legal War Over Health Reform

Jun 10, 2011• 10

By TIMOTHY JOST

For a lawyer, the argument of Florida v. the Department of Health and Human Services before a three judge panel of the Eleventh Circuit Federal Court of Appeals on Wednesday, June 8, was a beauty to behold. (For a non-lawyer it was probably tedious, repetitive, and much too long). Three active and very well-prepared judges spent two and a half hours grilling three very talented lawyers about intricacies of health policy and constitutional law, rarely allowing the lawyers time to finish a thought before interrupting with yet another question.

This is arguably the most important of the many Affordable Care Act (ACA) challenges currently pending in the courts. The plaintiffs include over half of the states, as well as the National Federation of Independent Businesses (NFIB) and two individual plaintiffs. It is one of only two cases in which a part of the ACA has been held unconstitutional (out of over thirty cases that have been filed), and it is the only case in which the lower court struck down the entire statute as unconstitutional. Thirty-six amicus briefs were submitted to the appellate court, including briefs filed by professional and provider organizations, members of Congress, states and state legislators (on both sides), Nobel Prize winning economists, law professors, disease and consumer organizations, and just about every conservative advocacy group in the country.

The attorneys. The importance of the case is underlined by the fact that the federal government was represented by Acting Solicitor General Neal Katyal, while the states were represented by Paul Clement, Solicitor General under the Bush administration, perhaps the first time two solicitor generals have squared off against each other in a court of appeals argument. (The NFIB was represented by a third well-known lawyer, Michael Carvin).

Quality Like Beauty Is In the Eye Of The Beholder

Jun 10, 2011• 8

By HUMPHREY TAYLOR

For as long as I can remember we have told ourselves that the health care priorities of the American people are access, cost and quality. However there was never a consensus as to what exactly we meant by quality, let alone how to measure it, or pay for it. The truth is that there are many ways of defining quality and our research shows that different players define quality very differently. Patients, physicians , employers, insurers, the I.O.M, hospital managers, drug companies, the NCQA, public health experts, demographers and policy wonks all focus on different indicators of quality. Clearly quality, like beauty, is in the eye of the beholder.

Patients tend to define quality as meaning affordable access to almost everything. Naturally they care about the outcomes of their own care. They tend to believe that more care is better than less. The demeanor and bedside manner of doctors and nurses, being treated with respect and courtesy, are important. They often judge hospitals the way they judge hotels; good food and a nice atrium make a difference. As Ian Morrison has written “good quality is being in a waiting room with people who have more money than you”.

The Institute of Medicine has equated quality with the avoidance of medical errors (adverse events) and patient safety , and the pursuit of ways to improve these.

Most Employers tend to equate quality with having happy , uncomplaining employees at the lowest possible cost. A minority of progressive employers , such as those who participate in the NBGH and PBGH meetings, also focus on “value” and the use of sticks and carrots to influence the behavior of their employees and pay for performance incentives to influence providers.