In the coming days and weeks we’re going to start rolling out a lot of video from last week’s Health 2.0 Conference held in San Francisco, CA on October 7-8, 2010. There is a ton of material to show you. But we’re going to start with one of the more remarkable demos at the conference. This is Gideon Mantel, Co-Founder and Chairman of First Life Research showing his company’s search capabilities which are able to comb millions of user-generated posts and comments to spot emergent trends in health experiences. His two examples are early detection of side effects in pharmaceuticals, but when you understand what they are doing, you’ll be amazed not only at the technology but also at the potential for converting messy narrative into actionable information.
Above the Fold
Tugging on Superman’s Cape
By BOB WACHTER, MD 
Several years ago, I spoke at Baylor College of Medicine in Houston, where Michael DeBakey, the legendary heart surgeon, was master of the universe for nearly half a century. I heard lots of DeBakey stories during my visit, but one in particular really stuck with me. “A few years back,” someone told me in a voice of hushed reverence usually reserved for descriptions of flawless beach days and single malt scotch, “he performed 16 open heart operations in a single day.” This was clearly intended to impress, but all I could think was, “Boy, I wouldn’t want to be patient #16.”
Lacking any information to help us understand when fatigue trumps even legendary prowess, such monumental tales of endurance can take on Man of Steel proportions. But a recent study in the Journal of the American College of Radiology may be the start of efforts to trim Superman’s cape.
Researchers from the Universities of Arizona and Iowa observed radiologists as they reviewed a handpicked set of 60 bone x-rays, half with fractures and half without. As their eight-hour workdays wore on, the radiologists’ accuracy fell by an average of 4%, with equal drops in sensitivity (missing a true fracture) and specificity (incorrectly calling a fracture when there was none). The degradation in performance was statistically significant.
First Bend in the Health Care Cost Curve
By PAUL LEVY
Recent trends in radiology imaging portend a dramatic and rapid reduction in this segment of a hospital’s business plan. Even before capitated (or global) payments have come into full play, there has been a large reduction in the number of some types of imaging studies in hospitals.
Our Chief of Radiology summarizes our experience — common to other hospitals as well — and provides some of the reasons.
The biggest hit has been in CT, the modality we are most dependent on for revenue. We are about 10% down in CT cases from last year, due to a combination of patient and physician fears about radiation exposure, more prudent ordering of studies by physicians, leakage out of the medical center, and the introduction of physician incentive programs (to minimize the amount of imaging) by some insurers.
Also, and very surprising, we have not seen an upswing in ultrasound or MRI to match the CT volume drop. We have, however, seen an increase in the number of patients arriving with their scans on CD ROMS having been imaged at other lower priced vendors. We don’t bill for these interpretations even though we are frequently asked to reinterpret the studies for our clinicians, and BIDMC is paying to store these images on our PACS systems.
By the way, this occurred while our overall patient volume increased during the same period.
The result of these trends will be to reduce the number of radiologists working in hospitals, and there will also probably result in a reduction of salaries for this physician specialty.
Paul Levy is the President and CEO of Beth Israel Deaconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.
Northwestern Memorial Hospital Faces a Brave New World
By David Dranove
If you have read my earlier blogs, you know that I am writing a book about the organization of healthcare delivery. A recent story in the Chicago Tribune reminds me that I need to keep my nose to the grindstone. The article told of changes underway at Northwestern Memorial Hospital. In order to prepare for new payment models, the medical staff and hospital want to create something along the lines of an Accountable Care Organization. The ACO will accept an “all-in” fee for treatment of specific conditions. The ACO makes money if it can keep costs under the fee and receives bonuses if quality objectives are met. The ACO model, or versions of it, have floated around for some time, and prepayment is certainly not new. What is new is that payers will now prepay for all costs associated with episodes of care, as opposed to prepaying hospitals for inpatient stays, or prepaying primary care physicians for a year of primary care.
The ACO model tries to better align the payment modality with the “product” that patients would naturally purchase. This should, in theory, lead to a matching of incentives with production. Hospital prepayment leads to a shift to outpatient care. Primary care physician prepayment leads to too much hospital care. Episode of illness prepayment should eliminate these gaming incentives.
Northwestern Memorial and its medical staff still face a dilemma. Should they create a new third legal entity to accept the prepayment, or should the prepayment go directly to the hospital or medical foundation? More importantly, should the hospital and medical foundation become partners in the new venture, or, more radically, unite into a single entity without creating the new entity? Healthcare executives have not always approached this question in the most thoughtful manner, as this short film painfully shows. (Painfully funny if you approach it with the right mindset.)
Integration has many positive connotations, and executives who create new integrated organizations can usually keep their boards at bay. This may explain why so many executives are eager to integrate. But integration comes with numerous challenges. It will take an entire book to make this argument clear, but consider the following two questions. First, what happens when physicians switch from being entrepreneurs to being employees? Second, accepting all-in capitated payments turns the ACO into a de facto insurance company. Will the ACO have the capabilities to be an effective insurer? I hope that Northwestern Memorial does not face the future with its eyes wide shut. Many hospitals have fared quite poorly by jumping on the integration bandwagon without understanding the risks.
David Dranove is the Walter McNerney Distinguished Professor of Health Industry Management at Northwestern University's Kellogg Graduate School of Management, where he is also Professor of Management and Strategy and Director of the Health Enterprise Management Program. He has published over 80 research articles and book chapters and written five books, including "The Economic Evolution of American Healthcare and Code Red". He has a Ph.D. in Economics from Stanford University.
The Massachusetts Connector: Success or Just a PR Coup?
By ROGER COLLIER
With the passage of insurance exchange legislation in California, and the release of a template for state exchange statutes by the National Association of Insurance Commissioners, many state eyes are turning towards the only existing exchange comparable to that required by PPACA: Massachusetts’ Connector.
The Connector, which offers Commonwealth Care subsidized coverage for those with incomes below 300 percent of FPL but not eligible for Medicaid, and Commonwealth Choice private plans for other families and individuals and small employer groups, has been touted as a major success by current and former Commonwealth officials and many national reform advocates.
But, after four years of operation, just how successful has the Connector really been? Has it simplified health plan choice and enrollment, increased the number of insured, reduced marketing costs, created competition, or driven down premiums? It turns out that the answers are far less positive than the Connector’s boosters have admitted.
HAS THE CONNECTOR SIMPLIFIED PLAN SELECTION AND ENROLLMENT?
For some, at least.
For the 33,000-enrollee unsubsidized CommChoice program the answer is yes. Health plan selection and enrollment for the seven plans (with six levels of benefits each) is directly available via the Connector website, with simple well-designed screens and navigation, and easy comparison of alternatives. Even so, only half of thepost-reform non-subsidized insured have chosen coverage via CommChoice.
Letting the Data Flow, Part One
By JOHN MOORE
Making clinical data liquid permeated a series of events I attended last week during Health Innovation Week in San Francisco. Monday and Tuesday found me at the HIE/REC conference. Wednesday was HealthCamp at Kaiser-Permanente’s Garfield Research Center (KP was extremely gracious in hosting this event and the opportunity to get a tour of the facilities prior to event kick-off was great). The week concluded with the annual and well-orchestrated Health 2.0 conference.
This first post will focus on the HIE/REC event as it was quite distinct from the other events: smaller audience, more staid, dominated by government officials and tied at the hip, for good and bad, to the existing healthcare system infrastructure.
The HIE/REC conference was an odd event with attendance hovering around 200 or so attendees. The event was focused almost entirely on what the States are doing with the federal funds coming their way to establish Regional Extension Centers (RECs) whose main objective is to get priority primary care physicians (PPCPs) to adopt and meaningfully use a certified EHR. Now, having been to this event and heard many of the State REC initiatives that are now underway via this program, sad to say that my original opinion has not changed. Rather than picking preferred EHRs and assisting with deployment, these RECs may be better off just helping to these PPCPs understand exactly what the HITECH Act is, what are their options, what questions to ask of a vendor or service provider and leave it to EHR consultants and vendors to take it from there.
Physician Report Cards: Don’t Shoot the Messenger
By
There is a BIG difference between the popular consumer/physician matching Websites such as: Vitals.com, RateMDs, Angies List, Healthgrades, Zagat and UCompareHealthcare (a NYTimes property), and the other initiatives in place to monitor physician performance as driven by hospitals, government and other payers and health plans. Soon, these differences will be merging with the more complex score cards from hospitals joining forces with the consumer tools.
OPPE (Ongoing Practice Performance Evaluation) and FPPE (focused Practice Performance Evaluation) are initiatives set in place by The Joint Commission (TJC), an arm of the American Hospital Association that accredits health care organizations. These initiatives are coming main stream to provide structured and frequent review of a hospital’s physician personnel. There is nothing new about these initiatives, (TJC has always been a follower in health care business intelligence), but soon ongoing reporting will be required by all and supplied by a variety of experienced commercial firms.
Private enterprise has been helping hospitals benchmark, profile and rate physicians on a broad spectrum of metrics relevant to specific acute service lines for decades. Of course mortality, length of stay, risk-adjusted complications rates, patient safety events and indicators, patient satisfaction, and a long list of Core Process Measures have all been part of that analysis. Progressive hospitals have been sharing this information with physicians, and for the most part physicians have accepted that the profiling analytics have done a good job of educating them on their performance. Medical Evaluation Committees have their hands full with information to help credential and reappoint physicians to hospital privileges, and a more informed dialog has been fostered.
Patients 2.0 – The Growing Demographic of Networked Patients
In a ballroom at the Hilton Union Square in San Francisco last week, several hundred people shared ideas, debated, and painted a multi-faceted picture of the NewPatient: the networked patient.
The meeting was convened, in “unconference” style, in conjunction between the Health 2.0 Conference and Gilles Frydman, founding father of ACOR, the Association of Cancer Online Resources. Gilles knows a lot about the NewPatient: he’s organized people focused on cancer for over 15 years through his organization, which has helped tens of thousands of health citizens connect to clinical trials, researchers, information, and each other – all seeking to cure virtually every form of known cancer, and identifying forms unknown.
As Jeremy Shane of Health Central kicked off the meeting, he set the theme: this session was, “Not Meet the Parents, but Meet the Patients.” As Health Central sees 14 million visitors to its sites on a monthly basis, Jeremy has some knowledge about the NewPatient, too.
What makes an engaged patient, he has learned, isn’t based on a demographic such as age or gender or socioeconomic status, per se; what makes an engaged patient is a desire to understand her situation and a driving curiosity – in sum, a “need for cognition and understanding,” Jeremy contends.
Jeremy notes that the average search on health has grown from 4 words just a couple of years ago to 6.5 words today — a longer tail – because people are describing their unique situation and they want an answer to their own needs.
Healthy Eats For Data-Hungry Doctors
By DAVID C. KIBBE, MD, and BRIAN KLEPPER, PhD
Imagine that an innovative health plan – aware that half or more of health care cost is waste and that physician costs to obtain the identical outcome can vary by as much as eight fold – hopes to sweep market share by producing better quality health care for a dramatically lower cost. So it begins to evaluate its vast data stores. It’s goal is to identify the specialists, outpatient services and hospitals within each market that, for episodes of specific high-frequency or high value conditions, consistently produce the best outcomes at the lowest cost. Imagine that, because higher quality is typically produced at lower costs – there are generally fewer complications and lower incidences of revisiting treatment – the health plan will pay high performers more than low performers. Just as importantly, it will limit the network, steering more patients to high performers and away from low performers.
Suddenly, it will become very important for physicians and other providers to understand, in detail, how they compare to their peers within specialty, and how to provide the best care possible. And if they find the results aren’t so positive, they may want to figure out where their deficiencies lie, and how they can improve.
Now imagine that clinicians could easily view data about their patients and themselves.
- Basic demographics: e.g. age, gender, length of time since last visit.
- A problem list based on diagnoses within the past year.
- A list of medications prescribed, including ordering physician, dates and fulfillment information.
- A list of lab tests ordered, by physician and date.
- A list of immunizations.
Suppose the clinician could review, revise or copy this information to create a lasting “patient profile,” saving it online and retrieving it for use at each subsequent visit as appropriate.
The Health 2.0 Connection
Regina Holliday paints at Health 2.0 while Aneesh Chopra talks. (Photo from Gilles Frydman)
