The Health Care Blog – Page 719 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

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An Alternative to Malpractice

May 25, 2011• 12

By JOHN GOODMAN

About three decades ago, University of Chicago law professor Richard Epstein proposed a radical alternative [gated, but with abstract] to our system of malpractice liability. He called it “liability by contract.” The idea: let patients and doctors voluntarily agree in advance how to resolve things if something goes wrong.

In nonmedical fields, Epstein’s idea is actually quite commonplace. Contracts for performance often have provisions detailing what the parties will do if something goes awry. If the parties disagree, contracts often spell out dispute resolution procedures (such as binding arbitration).

One version of this idea in medicine has already been tried. For years, hospitals asked admitting patients to sign a form agreeing not to sue the hospital or the doctors, no matter how negligent they were. When these forms showed up at the courthouse, however, judges routinely dismissed them on the grounds that the patients were too sick, too scared and too uninformed for there to have been a true meeting of the minds.

My colleagues and I at the National Center for Policy Analysis believe we have found here and here. Let the state legislature decide on the minimum elements (including the amount of monetary compensation) that must be in such contracts in order to make sure patients are fairly protected. Then widely publicize these elements so that people generally understand (before they get sick) what will happen if they opt out of the malpractice system. Courts would be required to accept these contracts as binding.

Do We Have Any Clue How to Cut the Cost of Healthcare?

May 24, 2011• 60

By ROBERT WACHTER, MD

At the Society of Hospital Medicine’s annual meeting last week in Dallas, Lenny Feldman of Johns Hopkins presented the results of a neat little study. His hypothesis: physicians given information about the costs of their laboratory tests would order fewer of them.

Feldman randomized 62 tests either to be displayed per usual on the computerized order entry screen or to have the cost of the test appear next to the test’s name. Some of these were relatively inexpensive and frequently performed tests. After randomization, for example, the costs of hemoglobins ($3.46) and comprehensive metabolic panels ($15.44) were displayed, while TSHs ($24.53) and blood gases ($28.25) were not. He also randomized more expensive tests: the costs of BNPs ($49.56) were displayed, while hepatitis C genotypes ($238.62) were not.

The educational intervention was surprisingly powerful. Over the six-month study, the aggregate expenditures for each test whose costs were displayed went down by $15,692, while non-displayed tests had a mean increase of $1,718. Over the entire group of 31 tests whose costs were shown to physicians, costs fell by nearly $500,000.

Coincidentally, last week’s Archives of Surgery reported the results of an intervention aimed at decreasing lab ordering on the surgical services of Rhode Island Hospital. There, simply announcing the service’s overall expenditures on non-ICU laboratory tests for the prior week at a house staff conference led to significant savings: $55,000 over an 11-week study period.

Have we found the Holy Grail, the key to flattening the cost curve? A little physician education leads to increased awareness of the cost consequences of their choices and, voila, our economy is rescued from the brink of disaster. How nice.Continue reading…

Numbers Instead of Letters

May 24, 2011• 5

By KARI GORDER

780.4: Dizziness and Giddiness.

Deep breath: I still felt out of place. I turned the engine off. Quietly, I promised myself: once you get commissioned, maybe after you go through ODS, they’ll give you a Geneva Conventions ID card and you can stop showing your driver’s license at the gate. You’ll have a uniform and you won’t be the only one on base wearing jeans. You won’t have to be on a guest list.

I got out of my car and walked inside. The National Naval Medical Center was a labyrinth, but this was my third and final physical—putting a bow on the package, as my recruiter had told me—and I knew my way to the health center. As I sat between two men waiting for their pre-deployment physicals, I couldn’t have felt less proud. An academic in a hornet’s nest. But, I promised myself: one day you’ll deploy too—as a doctor—and serve your country. One day you’ll use the Arabic you spent four years in college studying. You’ll be able to tell your children that you fought in war. You’ll justify your departure from the intelligence community: to be one who does, not one who says. I thought of a picture hanging in my bedroom. Deep breath.

The path to a military scholarship for medical school is lengthy: background investigations, essays, fingerprinting. Letters of recommendations from current or retired officers; my grandfather wrote mine. A personal interview with a current military physician: I got taken out to lunch by a Navy doctor who also happened to be a reality star, and then got mentioned in a gossip blog. And of course, a slough of physicals. Today I was to go over the results of my blood work from the previous appointment, and sign the appropriate forms. My insurance company had faxed over the entirety of my medical records, including my broken arm at the age of 7. I was tying the bow. I wiped my palms on my jeans.Continue reading…

NPfIT Blazing the Trail

May 24, 2011• 5

By MARGALIT GUR-ARIE

The National Audit Office (NAO) in the UK has recently published a report evaluating the status of “The National Programme for IT in the NHS” (NPfIT). The program is a very ambitious top down initiative to deploy Health Information Technology across all NHS facilities in an attempt to provide an electronic care record for every patient in the UK. The blunt conclusion of the report states that “The original vision for the National Programme for IT in the NHS will not be realized” and “This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme”. Is this gloom ridden report in any way pertinent to our own quest for an EHR for every patient by 2014? Of course not. We don’t have a Socialist system where the government can decide on a particular EHR product, buy it, contract billions of dollars in services, and force all hospitals and doctors to install it and use it in their facilities on a government dictated schedule.

Instead, the United States Government is building a National EHR, and I find the business model fascinating. No, the Feds did not hire a team of software developers, did not set up a business entity and didn’t even hire a defense contractor to do all these things. Instead, they legislate and engage in a flurry of rule makings which are then applied in quick succession, like giant levers, to the delivery side of our health care system. This is nothing short of brilliant.Continue reading…

Patient Care in the Cloud

May 23, 2011

By VIJAY GOVINDARAJAN AND JUSTIN CHAKMA

When we envision an emerging market, we think of a rapidly growing country with small purchasing power, little infrastructure, and diminishing natural resources. These three aspects of emerging markets require innovations that can subsequently be taken global — a phenomenon known as “reverse innovation.” However, a fourth and powerful driver of reverse innovation is the comparative absence of intermediaries: an institutional gap.

As Tarun Khanna has described, institutions such as venture capital firms, legal support, universities, regulators, and third-party auditors help to make markets and value chains more efficient. Institutional voids can persist for decades, and cannot be resolved by throwing more capital at the problem. They also differ from physical infrastructure and limited natural resources, as they often manifest themselves in non-physical forms.

A concrete example of an institutional void is universities for training physicians. It takes more than a decade to train medical specialists. Building new medical schools or expanding existing ones will only have an impact on the needs of the local healthcare system in the distant future.

Medtronic is exploring ways to address that void in the area of chronic disease management.

Sixty-nine percent of deaths in the developing world are due to chronic disease, yet only 2.3% of international aid is allocated to chronic disease. In the United States, hospitalization of chronic disease patients accounts for the majority of health care costs. But innovation in managing chronic disease is happening faster in emerging markets such as India as a result of the scarcity of physicians.

India, which has more than one billion citizens, has only 100 qualified cardiac electrophysiologists. To tackle this institutional void, Medtronic developed a low-cost, pill-sized pacemaker that can be inserted into a stent, then embedded in the heart. This device eliminates the need for invasive inter-cardiac leads that deliver electricity to synchronize the heart. A much larger group of cardiologists and cardiac surgeons will be able to perform this procedure.Continue reading…

How to Blow the Big One: A Methodology

May 21, 2011• 21

By JOE FLOWER

[Note to the reader: Anything that is in italics and square brackets (such as this note) is addressed to you, personally. Yes, you. Try it on, see if it fits.]

Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries.

We’re not talking a little better, skipping a few unnecessary tests, cutting the percentage of surgical infections a few points. No. Don’t even think about it. We’re talking way better. Save the children, help the people who should know better, nobody dies before their time, no unnecessary suffering. Seriously.

I don’t know how high you want to aim, but personally, I think we should aim at least as high as the cutting-edge programs and facilities that are already out there, in the system as it exists today, cutting real healthcare expenses of real people, even “frequent fliers,” by 10, 20, even 30 percent, while making them healthier, much healthier. At least. To me, that’s a wimpy goal, just doing as well as some other people are already doing. Because these programs are just getting off the ground. They’re in the first few iterations. The stretch goal, the goal we can take seriously, is to cut real costs by 50 percent, by making people healthier. There is at least that much potential out there.Continue reading…

The Fall and Rise of Asynchronicity

May 21, 2011• 1

By PAUL LEVY

The daughter of a friend was bemoaning poor connectivity of the internet at a university in Europe. She said, “It’s vital since I don’t have any other method of communication.”My friend noted, “I was telling her how we only had letters and occasional long distance phone calls in college….”

One of my most widely read blog posts was entitled, “Blackberry Cold Turkey,” in December of 2006. The impetus was when my telecom provider wrote in November to tell me that my bare bones wireless data service was going to be discontinued, but that I could “upgrade” to one with a higher price with more functionality, if I also bought a new device. I decided it was time for a life-changing experience and tossed my Blackberry in the trash. This reminded me of a major functionality of email.

The most important attribute of email is the asynchronicity of the medium: The sender and the receiver do not have to be in contact at the same moment. This enables efficient communication. You can integrate emails into the fabric of your life. You originate a message when you want, and you reply to another’s when you want.

Until the “revenge effect” occurs! How does this work? Email was invented. Then Blackberries were invented so we could be sure, when we are away from our computer, to receive emails as soon as they are sent and reply to them immediately. In fact, we feel compelled to read and respond in real time. Asynchronicity disappears.Continue reading…

Health 2.0 Pavilion @ Maker Faire Bay Area THIS WEEKEND

May 21, 2011

By MATTHEW HOLT

Maker Faire Bay Area is the worlds biggest DIY and tinkerers festival–at the San Mateo County Fairgrounds (about 20 mins south of San Francisco). I’ve heard it called a cross between the Home Depot & Burning Man. And this year for the first time, Health 2.0 is there with its own pavilion and lots of great speakers–and lots more hands on activity. Below is one photo and there are more on Health 2.0 News.

Here’s the Health 2.0 Stage schedule, with our own Lizzie Dunklee taking the stage at 11 am this morning to kick it all off.

My Own Story of ALS

May 20, 2011• 5

By AL LEWIS

I would like to introduce our newest regular contributor, Al Lewis. Some of you might recall him from his guest-postings, sometimes offensive, usually controversial but always based on both fifth-grade arithmetic and principles of economics, two subjects that he respectively took in fifth grade and taught for two years at Harvard.

Al is asking for a tiny bit of help from us, which is to go to his ALS site and “like” it and maybe add a facebook comment. He is trying to get CMG Marketing (the official licensing contractor for Major League Baseball) to sell Lou Gehrig jerseys to raise money and awareness for ALS. Increasing the popularity of that site increases the likelihood of his getting CMG’s attention with his fundraising idea. – Matthew Holt

It occurred to me that I have yet to post my own story in detail, and some of you asked me to do that after seeing my wedding photo.

Janet and I had dated for a while, and though we had broken up, we had become more like “besties” when she started to feel that something was amiss. I (and other close friends) took her to several doctors to try to discern what was wrong. I know many of you experienced the same thing with your loved ones, where you had to visit multiple doctors before getting a diagnosis. Then came the day — and no doubt you had a similar day too — when you finally get the definitive diagnosis. The Mass General neurologist, Dr. Cros, had very thoughtfully scheduled this visit as the last one of the day, so that the four of us there could be in his office into the evening, asking questions, holding back tears, cross-examining him to make sure we hadn’t overlooked any possibility for treatment, even something in early-stage clinical trials, with mice even.

After that, we went about our lives. Of course I continued to be supportive as best friends would be. But I couldn’t stand to watch her deteriorate in front of me like this. At one point her condition had declined so much that at her health club (Mt. Auburn) where she had been a member of for 20 years, someone asked what was wrong. About a day after I told the person at the front desk, the manager wrote back and said he was going to comp her membership for the rest of her life.Continue reading...

High costs cut drug use…and not in a good way

May 20, 2011• 3

This pretty interesting study from Avalere Health confirms what several others have shown. If you add a user fee to any medical procedure people use less of it. And of course their decision to use it less is not based on whether it’s medically necessary or not; it’s based on how much it costs and what their income is. The difference with this study is that it’s about the use of expensive cancer drugs which are increasingly oral, now that oncologists aren’t being rewarded as much for delivering them via infusion. Co-pays of $500 or more saw “abandonment” rates of 25% or more. Other factors creating increased rates of abandonment included lower income (duh) and whether the patient was covered by Medicare or commercial insurance. The study was (of course) funded by a gaggle of drug companies. They didn’t fund the (non-existent) parallel study of which of these drugs actually did the cancer patients any good, but it’s not logical that cost should be the determinant of whether a drug–especially presumably a life-saving one–gets used.