The Health Care Blog – Page 738 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Are Patients and Interoperability Finally Coming to the Fore of Health IT?

Mar 25, 2011• 4

By ADRIAN GROPPER, MD

In recent weeks, I’ve witnessed a huge change among my practicing colleagues. For the first time, the true cost of vendor-proprietary records is seen as an existential issue for practices that may need to join an Accountable Care Organization to survive.

To a doctor in the good old days, IT meant practice management as a tool to get paid. As the days of fee-for-service give way to ACOs and global payments, doctors are starting to realize the direct link between payment, health records and patient engagement.

In a recent essay titled “Show Me the Money” in Patient Safety and Quality Healthcare, Barry Chaiken, MD summarizes:

“Regular assessment of quality performance will identify those providers who might be withholding care or over-utilizing care, helping to balance the equation between clinical and financial objectives. Entities such as ACOs and patient-centered medical homes will either take on the financial risk and therefore share in the savings generated by their transformed care delivery processes or receive added payments, along the lines of current pay-for-performance schemes, for delivering predetermined clinical and financial outcomes.”Continue reading…

The Incredible and Wasteful Complexity of the US Healthcare System

Mar 24, 2011• 152

By HUMPHREY TAYLOR and IAN MORRISON

During the health care reform debate, we wrote that most people’s attitudes to it were “confused, conflicted, clueless and cranky.” A major reason was that the American health care “system” is fiendishly complicated and few people really understand it. As a result hardly anyone knows much about what is actually in the reform bill (but that does not prevent them from having strong opinions about it). Sadly, the reforms, whatever their merits, will make the system even more complicated, the administration more Byzantine and the regulatory burden more onerous.

System complexity.

The American healthcare system is already by far the most complex and bureaucratic in the world. We were once asked to spend ninety minutes explaining American health care to a group of foreign health care executives. Ninety minutes? We probably needed a few weeks. Most other countries have relatively simple systems, whether insurance coverage is provided by a government plan or by private insurance or some combination of these. But in the United States insurance coverage, for those who have it, may be provided by Medicare Parts A, B, C, and D, 50 different state Medicaid programs (or MediCal in California), Medicare Advantage, Medigap plans, the Children’s Health Insurance Plan, the Women, Infants and Children Program, the Veterans Administration, the Federal Employees Health Benefits Program, the military, the hundreds of thousands of employer-provided plans and their insurance companies, or by the individual insurance market. This insurance may be paid for by the federal or state governments, by employers, labor unions or individuals. Some employers’ plans cover retirees, others do not. The result is that the system is pluralistic, mysterious, capricious and impossible for most patients and providers to understand.

Administrative complexity

The administrative complexity is amplified by the multiplicity of insurance plans. About half of all Americans with private health insurance are covered by self-insured plans, each with its own plan design. Employers customize their plan documents, led by consultants who make a good living designing their plans and tailoring their contracts. As one prominent consultant told us recently, if all the self-insured plan documents were piled on a table they would not just exceed the 2,700 pages of Obamacare, they would probably reach the moon. For the rest of the commercially insured population, health plans may be traditional indemnity plans, Preferred Provider Organizations or Health Maintenance Organizations.

The coverage provided by different plans varies dramatically. They may or may not include large or small deductibles, co-pays or co-insurance. Beneficiaries may pay a large, small or no part of their health insurance premiums. Some plans cover dependent family members and children, others do not. The Medicare Part D pharmaceutical benefit plan involves a “doughnut hole,” which will disappear as health reforms are implemented. Surveys have found that few people fully understand their own insurance plans let alone the bigger picture. While health reform takes some steps toward standardization of insurance offerings and improving transparency, overall it is likely to increase complexity.Continue reading…

Is That Thorazine in the Baby’s Bottle?

Mar 24, 2011• 5

By PSYCH GRIPE

One of the most disturbing trends in mental health today is the increasing use of powerful antipsychotic medication to treat behavioral problems in children, even very young children. According to a 2009 report by the Food and Drug Administration, there are 500,000 children in the United States being administered regular doses of antipsychotics. Medicaid data shows public health monies spent on antipsychotic drugs for children exceeding $30 million in New Jersey and topping $90 million in Texas. It is a trend that has built relentlessly for the past ten years and continues unabated.

I find the use of these drugs on children to be appalling almost beyond words. Having worked as a mental health professional for many years, I am well acquainted with these medications. This class of drugs, sometimes referred to as neuroleptics, are major tranquilizers and are primarily used and intended for controlling hallucinations and delusions in cases of psychosis and schizophrenia. For an adult with severe schizophrenia, these medications may be a glimmer of hope, but it is always a difficult risk-benefit analysis because there are potentially severe side effects and reactions. Permanent neurological damage can occur in the form of tardive dyskenisia, and sudden death can occur from a reaction called neuroleptic malignancy syndrome. With newer forms of antipsychotics, these type of side effects are less frequent and less severe, but continue to be a risk depending on the reaction of the individual’s body. However, newer, “atypical,” antipsychotics present new dangers to the patient, metabolic changes that result in a dramatic increase in the instances and severity of diabetes and heart disease. The result is that adults on antipsychotic medications have a life span that is 20 years shorter then the average person.Continue reading…

No One Cares About Your Health (or No One is Willing to Pay For It)!

Mar 23, 2011• 9

By JOSEPH KVEDAR, MD

Of course that is not true, but it seems like that sometimes, doesn’t it? If you are working to promulgate a solution that promotes health in the context of our current healthcare system, there is no end to the challenges you will face. Lets think a bit about the various actors, why they should care and why they do not.

I’ll start off with you. No one should care more about your health than you. But as the behavioral economists remind us, we are not rational beings. We are more likely to focus on tangible things in the moment rather than long-term uncertain benefits. So we persist in participating in unhealthy behaviors that provide short-term pleasure and lead to downstream sickness. In addition, we’ve been addled into believing that once we are diagnosed, we are victims and that we can abdicate all responsibility for our care. (see 5-17-2010, Are Individual’s with Chronic Illness More Passive?). This insidious combination makes it hard to hold ourselves accountable for our own health. Most times, we’d rather blame the environment, or bad luck, and ask if we can take a convenient pill to make it better.

Next, how about your loved ones? They are the best targets. In most cases our loved ones (the more current phrase is ‘social network’) can and do affect our health (See Nicholas Christakis’ book Connected and related articles). It has, however, been challenging to get loved ones to open their wallet to pay for service offerings that improve your health. In my experience, this is most often because of the same mentality that makes you a passive victim once you get sick. We feel that society owes a victim. We all feel like we’ve paid into various insurance programs – public and private – and that they should be the ones to pay for health-related services, particularly in the setting of chronic illness. So your loved ones do care, but they have been trained not to open their wallet to support your care. I can think of a dozen or so business plans I’ve seen over the years where the service to support a chronically ill individual was to be paid for by the “sandwich generation.” There is an appeal to this on the surface, but I haven’t seen one of those businesses scale yet.Continue reading…

Nurse Staffing, Patient Mortality, And a Lady Named Louise

Mar 23, 2011• 12

By BOB WACHTER

How many nurses does it take to care for a hospitalized patient? No, that’s not a bad version of a light bulb joke; it’s a serious question, with thousands of lives and billions of dollars resting on the answer. Several studies (such as here and here) published over the last decade have shown that having more nurses per patient is associated with fewer complications and lower mortality. It makes sense.

Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.

Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.

As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”

The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings).Continue reading…

Sermo teams with J&J

Mar 22, 2011• 2

By Matthew Holt

One of the big stories at the Health 2.0 Conference in San Diego is that Sermo is partnering with Janssen Global Services (part of J&J) to create tools for doctors to help them move their patients through the health care system. It’s the first time Sermo has explicitly both added a mobile app and moved into the transactional end of its physician community members’ businesses. Sermo’s figured out that a significant portion of their referrals never result in an actual appointment. So they’re going to be working with Jannsen to help close that loop, and we can assume that there’ll be a series of physician and consumer-aimed services to come from the partnership. Sermo says to expect the first product by end of spring. While new entrants like Doximity are aiming at the same market, Sermo’s marketing reach and J&J’s muscle makes them a formidable competitor.

And if you’re at the Health 2.0 Conference in San Diego, Dan Palestrant, Sermo’s CEO will be making an appearance to explain a tad more!

The CMIO Should Be a Doctor

Mar 22, 2011

By MAGGIE MAHAR

A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center, “because nobody knows a doctor’s business like a doctor.”

As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.

It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.

On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.

It is telling that before coming to Maimonides in 1995, Brier spent fifteen years in New York City’s municipal hospital system, and still says: “Even though I’m not working for government anymore, I still feel that I’m a public servant.”Continue reading…

Who Owns Patient Data?

Mar 22, 2011• 11

By DAVID HARLOW

Walgreens is being sued by customers who are not happy that their prescription information – even though it has been de-identified – is being sold by Walgreens to data-mining companies.

The data privacy and security concerns surrounding the transfer of de-identified data are significant. To “de-identify” what is otherwise protected health information under HIPAA, some outfits will simply strip data of 18 types of identifiers listed in federal regulations. However, the relevant regulation (45 CFR 164.514(b)(2)(ii)) also provides that this only works if “the covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.” Thus, the problem with this approach is that, these days, nobody can disclaim knowledge of the fact that information de-identified by removing this cookbook list of 18 identifiers may be re-identified by cross-matching data with other publicly-available data sources. There are a number of reported instances of this sort of thing happening. The bottom line is that our collective technical prowess has outstripped the regulatory safe harbor.

Is this the basis of the lawsuit brought against Walgreens? An objection to trafficking in health information that should remain private? No. The plaintiff group of customers is suing to share in the profits realized by Walgreens from trading in the de-identified data.Continue reading…

What’s The Worst Case Scenario In Japan Nuke Crisis?

Mar 22, 2011• 4

By MERRILL GOOZNER

This from John Beddington, the United Kingdom’s chief science advisor at its Tokyo embassy:

Let me now talk about what would be a reasonable worst case scenario. If the Japanese fail to keep the reactors cool and fail to keep the pressure in the containment vessels at an appropriate level, you can get this, you know, the dramatic word “meltdown”. But what does that actually mean? What a meltdown involves is the basic reactor core melts, and as it melts, nuclear material will fall through to the floor of the container. There it will react with concrete and other materials … that is likely… remember this is the reasonable worst case, we don’t think anything worse is going to happen. In this reasonable worst case you get an explosion. You get some radioactive material going up to about 500 metres up into the air. Now, that’s really serious, but it’s serious again for the local area. It’s not serious for elsewhere even if you get a combination of that explosion it would only have nuclear material going in to the air up to about 500 metres. If you then couple that with the worst possible weather situation i.e. prevailing weather taking radioactive material in the direction of Greater Tokyo and you had maybe rainfall which would bring the radioactive material down do we have a problem? The answer is unequivocally no. Absolutely no issue. The problems are within 30 km of the reactor. And to give you a flavour for that, when Chernobyl had a massive fire at the graphite core, material was going up not just 500 metres but to 30,000 feet. It was lasting not for the odd hour or so but lasted months, and that was putting nuclear radioactive material up into the upper atmosphere for a very long period of time. But even in the case of Chernobyl, the exclusion zone that they had was about 30 kilometres. And in that exclusion zone, outside that, there is no evidence whatsoever to indicate people had problems from the radiation. The problems with Chernobyl were people were continuing to drink the water, continuing to eat vegetables and so on and that was where the problems came from. That’s not going to be the case here. So what I would really re-emphasise is that this is very problematic for the area and the immediate vicinity and one has to have concerns for the people working there. Beyond that 20 or 30 kilometres, it’s really not an issue for health.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at GoozNews, where this post first appeared.