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The Remarkable Rise of the Hyphenated-Hospitalist

Jan 16, 2011• 4

By ROBERT WACHTER, MD

I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful. We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalized patients. These were heady times.

I experienced déjà vu last week in a nondescript conference room at a San Francisco airport hotel, where the Society of Hospital Medicine and the American Hospital Association gathered a dozen folks to discuss specialty hospitalists. Representing the “traditional” hospitalist field (I never thought I’d say that) were SHM CEO Larry Wellikson, SHM co-founder John Nelson, SHM president-elect Joe Li, pediatric hospitalist Erin Stucky, and me. We were joined by AHA Senior Vice President John Combes. But the real stars were six leading physicians in new subspecialty hospitalist fields: a neurohospitalist (Dave Likosky), two surgical hospitalists (John Maa and Leon Owens), two ob-gyn hospitalists (Rob Olson and Ken Jacobs), and even an ENT hospitalist, Matt Russell. Here’s what I learned:

The Neurohospitalist: “The Neurologists Have Left The Building”

At my yearly hospital medicine CME course, I ask the 600 attendees what topics they believe they need to learn more about. The top answer is always neurology. Why? Because most neurologists are perfectly content to remain in their offices seeing headaches and neuropathy; few want the pressure and hassle of managing acute strokes or status epilepticus. When the neurologist “has left the building,” which is most of the time, medical hospitalists are left to pick up the pieces.

Dicker With Your Doc? Not So Fast…

Jan 15, 2011• 5

By JESSIE GRUMAN, PhD

“How to Haggle With Your Doctor” was the title of a recent Business section column in The New York Times. This is one of many similar directives to the public in magazines, T V and Websites urging us to lower the high price of our health care by going mano a mano with our physicians about the price of tests they recommend and the drugs they prescribe. Such articles provide simple, commonsense recommendations about how to respond to the urgency many of us feel — insured or uninsured — to reduce our health care expenses.

With unemployment at 9.4 percent and more than 50 million Americans lacking any or adequate health insurance, I understand the impulse of editors to assign this story. Plus, “of all the providers of medical care, physicians are most important in determining how much will be spent,” notes Arnold Relman in the New York Review of Books, since they make all the allocation decisions that “call on the facilities and services of all the other providers of care —hospitals, imaging centers, diagnostic laboratories, manufacturers of drugs and equipment.” The prices charged by these institutions vary widely and therein lies the opportunity to find some savings.

But coming off a wave of big-buck spending related to my recent diagnosis of stomach cancer, I am acutely aware that haggling with my doctor about the costs of my care is neither simple nor is it a matter of common sense. Rather, it is a matter of 1) understanding in detail both the opportunities and limitations related to my health insurance; 2) being persistent in information seeking, since price lists are often difficult to track down and comparisons of quality (accuracy) of laboratories and testing facilities are nonexistent; 3) using available information and my judgment to weigh options; 4) the willingness to risk the rejection of my request by my provider and perhaps antagonize her and 5) overcoming my pride and asking to be treated well while seeking the best value for my money.

Is There Something Wrong With the Scientific Method?

Jan 15, 2011• 17

By DAVE deBRONKART

A recurring them on this blog is the need for empowered, engaged patients to understand what they read about science. It’s true when researching treatments for one’s condition, it’s true when considering government policy proposals, it’s true when reading advice based on statistics. If you take any journal article at face value, you may get severely misled; you need to think critically.

Sometimes there’s corruption (e.g. the fraudulent vaccine/autism data reported this month, or “Dr. Reuben regrets this happened“), sometimes articles are retracted due to errors (see the new Retraction Watch blog), sometimes scientists simply can’t reproduce a result that looked good in the early trials.

But an article a month ago in the New Yorker sent a chill down my spine tonight. (I wish I could remember which Twitter friend cited it.) It’ll chill you, too, if you believe the scientific method leads to certainty. This sums it up:

Many results that are rigorously proved and accepted start shrinking in later studies.

This is disturbing. The whole idea of science is that once you’ve established a truth, it stays put: you don’t combine hydrogen and oxygen in a particular way and sometimes you get water, and other times chocolate cake.

Reliable findings are how we’re able to shoot a rocket and have it land on the moon, or step on the gas and make a car move (predictably), or flick a switch and turn on the lights. Things that were true yesterday don’t just become untrue. Right??

Bad news: sometimes the most rigorous published findings erode over time. That’s what the New Yorker article is about.

I won’t try to teach here everything in the article; if you want to understand research and certainty, read it. (It’s longish, but great writing.) I’ll just paste in some quotes. All emphasis is added, and my comments are in [brackets].

Truth or Consequences

Jan 14, 2011

By PAUL LEVY

While we are on the topic of medical errors, let’s see how doctors feel about disclosing them when the patient has not been harmed. Medscape recently surveyed doctors on this question and published the results in a provocative article by Gail Garfinkel Weiss entitled: ‘Some Worms Are Best Left in the Can’ — Should You Hide Medical Errors?” (A subscription is required, but it is free.)

To the doctors reading this, into which camp do you fall? To the patients reading this, what would you expect of your doctor in this kind of situation?

Some excerpts:

In response to the question “Are there times when it’s acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?” 60.1% of respondents answered “no,” and the remaining respondents were almost evenly divided between “yes” (19%) and “it depends” (20.9%).

Ready, Set…ACO?

Jan 14, 2011• 19

By JONATHAN BUSH

Happy New Year, everyone! 2010 was certainly action-packed, and 2011 promises the same.

I hear a lot of thunder about getting ready for ACOs.

This isn’t a crystal ball forecast, but I see hospitals spending tons of capex on new HIT from old-fashioned “software-based” companies, and it seems like the EMR is the new “pavilion.” I see hospitals buying medical practices using arrangements that are certain to require the hospital to subsidize doctor income. [For another take: Paul Levy on ACO.]

These two major waves are explained by clients and prospects alike as “readiness for ACO.”

I have three thoughts:

Don’t worry. We at athenahealth will do our part. If and when ACO payment models emerge, you won’t need to buy a new “module” from us in order to get payment. We will go get you that money the same way we are getting you the “Meaningful Use” stimulus payments, the P4P money, and the plain old health care reimbursements that we have always delivered. The changes to our technology and service needed to accomplish all that will be on us.
Don’t turn blue holding your breath waiting for the big bonus opportunity. The fundamental underlying principle of an ACO is that you will get a bonus in exchange for lower utilization. If that bonus is bigger than what you’d get from the utilization, then why would Medicare pay it? If that bonus is LESS than what you are getting now, why would you do it?
I have met newly elected Republican lawmakers of late and few of them are thinking that money will be saved with this approach. As with other aspects of health reform law, they appear to be eager to… well, let’s just say…scrutinize the mechanics closely.

None of this is certain and there will be exceptions to all the rules anyone tries to write.

This leaves one thing certain.

Do NOT make multi-year investments that depend upon ACO actually happening.

So as far as ACO goes, pay as you go.

With me?

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. He blogs regularly at THCB and at the athena blog where this post first appeared. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School. He blogs regulary at the athena blog, where this post first appeared.

The Myth of Consumer-Directed Health Care

Jan 13, 2011• 32

By JANE SARASOHN-KAHN

The theory behind “consumer-driven health care” is that when the health care user has more financial ‘skin in the game,’ they’ll become more informed and effective purchasers of health care for themselves and their families. That theory hasn’t translated into practice, based on data from the Employee Benefits Research Institute’s (EBRI) latest Consumer Engagement in Health Care Survey.

Health Reimbursement Accounts (HRAs) began appearing in employer benefit packages around 2001, with Health Savings Accounts emerging in 2004. 20% of large employers (with >500 employees) offered either an HRA or HSA plan in 2010, covering 21 million people or 12% of privately insured people in the U.S. Among these, there were 5.7 million accounts in 2010 containing $7.7 billion (including a couple thousand dollars from my own household).

Employees with HRAs and HSAs who exercised, didn’t smoke, and weren’t obese had higher account balances and higher rollovers than those who had less healthy behaviors.

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Jan 13, 2011

Doctors in Congress

Jan 13, 2011• 21

By RICHARD REECE

When new members of Congress are sworn in this January, there will be a total of 19 doctors in Congress – 3 Senators and 16 Congresspersons. That will be a 27% increase over 2009,from 15 to 19, in doctor members of Congress. These doctors will make up 3.5% of the 535 members of Congress, but will fall far short of the 10.7% who were signers of the Declaration of Independence.

Eighteen of the 19 new members are Republican. This may say something of the mood of America towards health reform, but it may have little effect on whether the health reform bill is repealed or retained in its present form.

Fifteen of the 19 are from the South or West, 5 are Ob-Gyn specialists, and 12 represent specialties who perform surgery. What this means or portends I do not know. Perhaps they will not hesitate to perform surgery on the bloated national budget and cut deficits. I take solace in recent polls, which indicate 77% of the public trust doctors to do right thing vs. 11% who trust Congress.

Here is the list of the 19 doctors in Congress:

Senate Incumbents

Tom Coburn (R, Republican), Oklahoma, family physician and ob-gyn
John Barasso (R, Wyoming), orthopedic surgeon New Senator
Rand Paul, (R, Kentucky), ophthalmologistContinue reading…

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Jan 13, 2011

Data Mining Case Reaches the Supreme Court

Jan 12, 2011• 7

By GLENN LAFFEL, MD, PhD

Twenty years ago, IMS Health got the idea to purchase prescription records from pharmacies, license physician information from the AMA’s Physician Masterfile, and link the two databases so as to create something new and different: prescriber-level data (PLD).

It was a brilliant idea. Almost immediately, pharmaceutical and device companies, government analysts and public health officials began lining up to buy raw PLD and/or the reports that IMS created from it.

And with good reason. By applying statistical tools to analyze PLD (a technique known in the vernacular as “Data Mining”) IMS and the purchasers of its data could obtain fresh insight into many topics of interest. These include prescribing pattern variations across regions, where and when influenza outbreaks occur, how physicians respond to these outbreaks and hundreds of others. Drug makers found PLD information to be particularly helpful. With it, they could refine marketing pitches and improve sales force efficiency, among other things.

Since those early days, the scope of the data compiled by IMS and other PLD providers has expanded to a point where it is truly breathtaking. The AMA Masterfile includes current and historical data on 880,000 physicians. IMS and similar companies collect information on more than 70% of all prescriptionsfilled in the US. SDI Health, another PLD provider, has billing information from 100% of inpatient and outpatient activity at 500 hospitals dating back to 2002. Their databases are large enough to detect national trends and withstand the most exquisite stratification analyses. Furthermore, PLD providers have perfected ways to exclude information from their databases that could be used to identify patients, so the data comply with HIPAA and other privacy-protecting laws.