I’m not quite as convinced as some that there’s too much difference in the amount of consulting being requested and required by health systems now compared to in years past. After all it wasn’t so many years ago that APM made every hospital in America buy physicians one year and sell them the next. And there’s been plenty of cash poured down the drain of Meaningful Use and EMR implementation. But this WaPo article manages to quote 2 of the 3 best known health futurists (FD I know them all well!) not to mention a bunch of others, on the topic of consulting being demanded in the ramp up to ACOs. So while journo Bara Vaida got quotes from Ian Morrison & Jeff Goldsmith, I’m concerned–couldn’t she find Joe Flower’s email?
Above the Fold
Minor League Report Cards
I was pleased to see the Chicago Tribune carry an op-ed piece this week by my friend and colleague Michael Millenson. The gist of the piece was that information about hospital quality is readily available online and we should use that information when choosing a hospital. Michael is right — there is no shortage of places to turn to get information about hospital quality. But I think he waxes too enthusiastic.
For one thing, it is not clear whether the widespread availability of quality information is a boon or a problem. Consider Medicare’s Hospital Compare website. Look up quality information for pneumonia and you are overwhelmed with nearly 20 different measures on four different web pages. I couldn’t possibly make sense of all this information even if I used sophisticated computer software; how could the average person sort through it all? One quality measure seems to stand out – mortality. But I wonder if this should be a major concern for pneumonia patients. Are we talking about 5 percent mortality rates, or 0.05 percent? I don’t know and Medicare won’t tell me.
HealthGrades.com is much simpler – it just reports mortality. The widely respected Leapfrog Group reports mortality for pneumonia and also reports another 8 general hospital quality measures, some of which are derived from even more measures.
When reading these report cards I find that my local hospital in Highland Park scores very well on mortality in the HealthGrades and Leapfrog reports but I can’t find it anywhere at the Medicare website. And I wonder if the low mortality rate is due to the hospital or due to the demographics of the patients. Michael Millenson pointed out that these report cards are risk adjusted, but he failed to mention that the available risk are pretty lousy – mostly controls for age, sex, and a few comorbidities. (Much better risk adjustment is possible but requires data not available to Medicare, HealthGrades, or Leapfrog.) Hospitals that get poor quality scores often report that their patients are sicker than the risk adjusters give them credit for. They might be right. Hospitals that get good scores never claim that their patients are healthier. Maybe they are hiding something.Continue reading…
Save Money on Medical Costs – Get Your Old Medical Records
There are many tips to saving money on medical costs like asking your doctor only for generic medications, choosing an insurance plan with a high deductible and lower monthly premiums, going to an urgent care or retail clinic rather than the emergency room, and getting prescriptions mailed rather than go to a pharmacy.
How about getting your old medical records and having them reviewed by a primary care doctor? It might save you from having an unnecessary test or procedure performed.
Research shows that there is tremendous variability in what doctors do. Shannon Brownlee’s excellent book, Overtreated – Why Too Much Medicine Is Making Us Sicker and Poorer, provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas. Some have argued that because of the fee for service structure, the more doctors do the more they get paid. This drives health care costs upwards significantly. Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.
Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
Doctors apparently seemed to order more tests. Patients, not surprisingly, agreed. After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?Continue reading…
Inspiration, spirit, connection, optimism–Health 2.0 Spring Fling
It’s been crazy post Health 2.0 Spring Fling in San Diego, I tried do my wrap of highlights and feelings from this Health 2.0 before the plane touched down last week, but I never quite finished them. So with a little hindsight, here are some snippets of my experience. Now this was just one experience–Indu and I will write a more detailed statement about what’s next for Health 2.0 soon–but clearly the feeling at this intimate and deeply personal Health 2.0 was more about feelings, spirit and emotion than it was about technology.
Karen Herzog has been virtually at every Health 2.0 and she said right at the end that several companies are teaching wisdom and mindfulness and that we need to merge Wisdom 2.0 (yes that’s a conference too) with Health 2.0. My flip response was that I’d been working in the health care system twenty years and had yet to see any wisdom in it. Not true of course, but as Arnie Milstein pointed out, we have a system that continues to diverge the trend lines between health care cost growth and GDP growth. And at some point that “shark” jaws will bite us.
What really struck me and struck Karen too, was that one of the keys Arnie discovered for communities with high performing but lower cost health care systems (in the US) was that the patients there really felt that the medical team cared about them. He asked the audience how many people felt the same about their care providers–and from around 300 people fewer than five hands went up.
Flipping the whole conference around, we started with a period of intensely personal fireside chats. America’s pediatrician, Alan Greene, talking about the one moment that can change the obesity epidemic–the Whiteout movement’s pledge to make each baby’s first bite of food be real food, not white rice baby cereal. Kolya Kirienko told an incredible story of recording his own patient narrative saved his life several times, and how he is now (funded by Robert Wood Johnson Foundation’s Project Health Design) building a narrative-capturing system that will really help patients record observations of daily living.
Finally an amazing troika of JD Kleinke (read his new novel Catching Babies), Amy Romano (@midwifeamy) and Health 2.0’s own mum to be Indu Subaiya dived into the amazing microcosm of our health system that is obstetrics. JD told Amy: childbirth is the one place where the patient has a choice to really opt out. You can’t have your hip replaced at home in a tub by someone the medical profession abhors. But you can have your baby “caught” that way. And Indu discussed how she as an MD made the decision to move from the trad OBGYN to a midwife and birthing center.
And not a demo in sight.Continue reading…
Does the GOP Have a Health Plan?
By JOHN GOODMAN
The Republicans have no plan to insure the uninsured.
How do I know that? A New York Times editorial told me. So did Ezra Klein, writing in The Washington Post. Matt Miller, also writing in the Post, went further. “I’m willing to repeal ObamaCare,” he wrote, provided the Republicans can “cover the same number of uninsured” and “do it at a lower cost.”
So why don’t the Republicans have a plan? That’s easy. “They’re against reform because it would cover the uninsured — and that’s something they just don’t want to do,” wrote Paul Krugman in The New York Times. The Times’ own editorial said the same thing.
All this has caused me to suffer a bout of severe depression. But, wait a minute. Wasn’t health care the biggest issue in the last presidential election? And…how memory fades…didn’t the Obama campaign spend millions of dollars…promoting his own plan?…no, that’s not right…
Ah, now I remember. The Obama campaign spent tens of millions of dollars on TV commercials attacking the John McCain health plan! It spent more money than has ever been spent for or against any policy proposal in the history of American politics.
The McCain plan, for all those suffering from collective amnesia, proposed to replace all existing health care tax and spending subsidies with a universal health grant, structured like a refundable tax credit. The Patients’ Choice Act version of the idea is sponsored by Tom Coburn (R-OK) and Paul Ryan (R-WI). It promises $2,300 (individual) or $5,700 (family) to everyone who isn’t enrolled in a government health plan.
So what was candidate Obama’s problem with that? Did he object that the plan wasn’t generous enough? Too few regulations? No, none of that. The Obama TV ads focused like a laser on raw self-interest. McCain’s health plan, the ads said, will cause your withholding taxes to go up (without mentioning the offsetting credit that would cause them to go down).Continue reading…
How the Veterans are Winning the War
At a seminar last night at the Center for Public Leadership at Harvard’s Kennedy School, one of the students asked a question along the lines of, “How do you know when you have done too much with regard to transparency?” My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI’s Jim Conway, as summarized here in an article discussing the BIDMC experience:
[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.
I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)
Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton’s article this week in the Wall Street Journal — “Data Spur Changes in VA Care” — documents this in more detail. Some excerpts:
Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.
The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals’ rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients’ ages and relative frailty.
“Why would we not want our performance to be public? It’s good for VA’s leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve,” Mr. Shinseki said in an emailed statement.
At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.
Seeing the data helped, says the Salem hospital’s chief of surgery, Gary Collin, because “you can become kind of complacent.”Continue reading…
Shaken, Flooded, Stressed by Power Outages, Fukushima Daiichi Moves into Second Place
Fukushima Daiichi, ca 1975
Two weeks ago, I wrote an article titled Nuclear plant issues in Japan are the least of their worries that attempted to provide a realistic prediction of the worst case consequences of the one-two punch from a very large earthquake and tsunami on a large nuclear power station on the coast of Japan. It has become increasingly apparent during the past week that my view from afar was not as clear as I would have hoped. I was overly optimistic about the final consequences of the events at Fukushima Daiichi.
On the catastrophic scale of commercial nuclear energy accidents, where Three Mile Island was in second place and Chernobyl was the clear leader, Fukushima Daiichi has moved into second. It is likely that it will end up to be far closer to Chernobyl than to Three Mile Island in overall economic, public health and geographic consequences.
Update: (Posted on March 27, 2011 at 0234) The above paragraph has been changed to specify commercial nuclear energy accidents to avoid complications with discussions about accidents that have occurred in the other aspect of nuclear technology. The commercial and military sides of nuclear are complicated enough to merit two mostly separate conversations. End Update.
There has been enough damage to the plants and enough radioactive material released to pose a danger to public health for someone who does not take any precautions, though actions to evacuate, shelter and monitor contamination have minimized the actual effects – so far. There have also been a fair number of plant workers and other emergency responders who have received substantial radiation doses in the range of 100-200 mSv (10-20 Rem). Those doses are about 20% of the dose required for early signs of radiation sickness (1 Sv or 100 REM) and at the threshold where there is a statistically significant increase in long term cancer risk.Continue reading…
Accountability? Heaven forbid!
At a recent talk, Dartmouth’s Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won’t be accountable.
This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:
[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal – improving care while containing costs. They’re seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.
Here’s the one I like best:
The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. “Providers are better positioned than CMS to determine which of their patients would be appropriate candidates,” the federation wrote.
So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.
The Thing to Watch in the Medicare ACO Regulations
By VINCE KURAITIS
Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico
What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?
Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule
. His list of five key design issues includes:
- How will patients be assigned to ACOs?
- To what cost benchmark will ACOs be compared?
- How will bonuses be calculated and paid?
- For which quality metrics will ACOs be responsible?
- What is the application process?
I’d like to add a sixth item — which actually would be #1 on my list.
As I’ve previously written, IMHO the central issue around ACOs is:
Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.Continue reading…
Does My Doctor Trust Me (and Does It Matter)?
Source: The Edelman Trust Barometer 2011
Members of the American public are frequently surveyed about their trust in various professionals. Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians. Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).
How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.
So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients. This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”
Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me. But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.
While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.
Here are nine of the 18 items of the trust scale. Clinicians are asked:Continue reading…
