The Health Care Blog – Page 786 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

How Come Comparative Effectiveness Research is All the Rage?

Oct 27, 2010• 18

By KENT BOTTLES, MD

Comparative Effectiveness Research (CER) is suddenly a hot topic at all the health care conferences. How come? Everybody agrees that we have to decrease per-capita cost and increase quality. Why? Government programs like Medicare and Medicaid foot more than 50% of our nation’s health bill, and if everything stays the same these programs will go belly up (bankrupt) in 8 years. Big problem.

Health and Human Services (HHS) has defined comparative effectiveness research as conducting and synthesizing research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in “real world” settings. In other words, CER is figuring out what treatments, tests, and drugs work and which ones don’t work.

John E. Wennberg spent a whole career at Dartmouth studying American medicine, and he comes to the startling conclusion that 60% of Medicare is spent on supply sensitive care (physician visits, consultations, imaging exams, and hospital and ICU admissions) and 25% on preference sensitive care (PSA tests, mammography, and elective surgery). Although we assume that this care is based on solid scientific evidence, Wennberg states that “medical science is virtually silent on such matters” as how often to see a patient, what test to order, and whether to admit a patient to the hospital or ICU. Some evidence based medicine experts state that only about 20% of what physicians do is based on sound science.

SureScripts, A Defacto NHIN

Oct 26, 2010• 10

By JOHN MOORE

Yesterday in New Orleans, SureScripts announced a new line of business: Clinical Interoperability. Leveraging their existing ePrescribing solution platform, currently serving over 200K physicians nationwide, and combining it with the technology stack of messaging solution provider Kryptiq, SureScripts will offer providers, EHR vendors, HIEs and other stakeholders the opportunity to securely share clinical information across town, the state, a region and the country. In this combination, SureScripts will provide the rails and Kryptiq will address the last mile of connectivity. This announcement has some pretty big implications for the HIE market. Chilmark was briefed prior to this announcement by both SureScripts and Kryptiq, following is what we learned.

Details:
SureScripts primary focus has been to provide the network that would support physicians transition to ePrescribing. Therefore, SureScripts has been focused on transmitting NDP data and not clinical notes. SureScripts got into the transmission of clinical summaries from one of its larger customers, MinuteClinic wanted to send clinical summaries of patient visits directly to primary care providers. In the past year SureScripts has facilitated the movement of over 0ne million patient summaries for MinuteClinic to primary care physicians using CCR. Seeing an opportunity, SureScripts sought a partner that could take this capability to the next level.

Kryptiq, a company profiled in Chilmark’s forthcoming HIE Market Trends Report due out next month, can be characterized as vendor of HIE capabilities that allow for the organic growth of an HIE without the overhead. Kryptiq has worked behind the scenes for a number of EHR companies to provide secure, structured messaging services within these EHRss ecosystems of customers connecting them to one another as well as to other systems, including SureScripts to facilitate care coordination.

Dear Mr. Smith…..

Oct 25, 2010• 15

By DAVID DRANOVE

John Smith of Chicago (not his real name) asked the following question in a recent letter to a local newspaper:

“Over the last several years my annual deductible has increased from $500 to $2000…With higher rates, I have had to limit key diagnostic services that my physician recommended at my physical. Does health reform cap deductibles…?”

The paper’s response mentioned that many preventive services are covered under the new law and mentioned something about risk pools – a decent enough answer I suppose. Here is what I would have written:

Dear Mr. Smith,

I understand that you are upset. No one wants to spend money on something when someone else has been buying it for them. Healthcare is no exception, and over the years we have gotten use to having our health insurance company buy everything our doctors ordered. The upside of generous health insurance coverage is that we are better able to avoid the risk of financial ruin. The downside is that we sometimes agree to receive medical services that we might not need. The latter is really true – the research evidence is overwhelming – and this has contributed mightily to the cost crisis you have been reading about.

Suing the Right to Life

Oct 25, 2010• 18

By LUCAS RESTREPO, MD

Last week, the fire department of a small town in Tennessee called South Fulton ignored the call of a man who needed help quelling a fire near his house. The firefighters declined lending a hand because the caller neglected to pay a $75 bill, the prerequisite for deserving assistance. The caller tried to put down the fire with a garden hose, but after two hours, his house caught on fire. When the property of a neighbor who had paid the $75 became threatened by the flames, the gallant firemen promptly answered the call of duty. The brave public servants prevented the flames from spreading to the property of their responsible contributor, carefully avoiding to suppress the conflagration’s source. Someone has to teach a lesson to the free-loaders in our society, explains a high-minded commentator.

Our health care system works exactly like South Fulton’s worthy fire department: we are entitled to health care only if we have money or qualify for Medicare or Medicaid. If you don’t have money, your health entirely depends on the charity of health care providers, who, as our admirable firefighters, may refuse to help.

I wish to argue that, besides being cruel and inhumane, the “South Fulton health care model” is a latent threat to society. The cost and effort of preventive medicine and basic primary care (fire prevention, putting down a small fire) is less than dealing with instances of end-organ failure (a house in flames). Moreover, having uninsured people (not aiming water to the fire source) creates a constant economic liability to responsible costumers (the neighborhood). On the other hand, why should someone become a doctor, nurse, or health insurance company founder (a firefighter) without being an altruist? Do firefighters dream of wealth and leisure?

The costs of not doing anything about a burning house are always paid in full by society ―and some costs are not immediately apparent. Who loves the sight and smell of a charred landscape? Where will the man live now that he has no house? Will he react violently to the inaction of the firemen? Will the reputation of the fire department (and the city’s) go up in smoke?

Crossing the ROAD to Real Reform

Oct 25, 2010• 3

By ALI KHAN, MD, MPP

“So, why didn’t I take the ROAD again?”

It’s a question that I regularly hear from many of my co-residents in internal medicine – and no, we’re not questioning our travel routes to the hospital.

We all know why we chose internal medicine: the intellectual challenges inherent in treating across organ systems, the excitement of primary scientific investigation and diagnosis and the like. As we struggle through the rigors of primary care training, however, it’s hard not to look wistfully at our colleagues in such lucrative, ”lifestyle” specialties as radiology, ophthalmology, anesthesia and dermatology – the “ROAD” to riches in modern medicine – and wonder exactly how green the proverbial grass on the other side might be.

In the wake of the Affordable Care Act’s [ACA] passage, conventional wisdom suggests that we’re about to find out. After all, with the ACA’s passage comes the influx of more than 30 million new customers to American primary care offices and hospitals. In a health care marketplace where just two percent of all graduating American medical students will pursue careers in general medicine (according to a 2008 JAMA study), an exponential jump in supply will mean a requisite increase in demand – with a boost in wages for primary care docs surely close behind.

Teamwork Training in Healthcare: More Than Just Kumbaya

Oct 22, 2010• 17

By BOB WACHTER, MD

One of the central tenets of the patient safety movement is that modern medicine is a team sport. Unfortunately, its players – particularly physicians – were trained and socialized to be free-spirited individualists. We need the Celtics of the 80s; what we have is a collection of young John McEnroes.

While this theory has been generally accepted, there is less agreement regarding how to change things. When I speak about safety culture, many of the questions I’m asked focus on how we are going to train future generations of medical students and residents to be “different” (translation: not like the prima donnas I have to deal with in my daily practice). It’s as if people are fatalistic about the ability to transform the culture of today’s practitioners; perhaps the next crop of physicians will do, and be, better.

Those of us who aren’t resigned to a biological solution to this problem have been enthusiastic about teamwork training and crew resource management programs for years. These programs are modeled on similar programs introduced in aviation in the 1980s after it was discovered that several tragic crashes had their roots in remarkably poor teamwork and communication. The programs bring together multidisciplinary groups to learn habits of clear communication and teamwork, and to be trained in the use of tools to employ when the going gets tough – such as, say, when a flock of Canadian geese flies into your jet’s engines.

Five years ago, with funding from the Moore Foundation, we implemented such a program on the medical services at UCSF and at two nearby hospitals. Unfortunately, while the program’s participants believed that it made care safer, our relatively small numbers of patients and providers left us unable to show improvements on hard outcomes like mortality. Other studies have had similarly mixed results – enough to keep the candle burning for those of us who believe that culture is critical and that teamwork training is the likeliest way to improve it, but not enough to catalyze a national movement for more. And, because it is expensive (the outlays for the trainers are only a small fraction of the costs – the real costs are the lost productivity of scores of nurses and doctors taking a day away from their regular jobs), teamwork training has mostly remained a novelty, implemented by a few cutting edge institutions and true believers.

How Reform Law Funds Itself, Strengthens Medicare, and Cuts the Deficit: Part 1

Oct 22, 2010• 58

By MAGGIE MAHAR

The Mainstream Media Rarely Tries to Explain the Congressional Budget Office’s nearly unbelievable claims that the Patient Protect and Affordable Care Act can:

1) Pay for itself

2) Provide coverage for 32 million uninsured Americans

3) Trim this nation’s deficit by some $143 billion over the next ten years

And, that’s not all. Medicare’s Trustees say that the reform legislation puts Medicare on the road to financial solvency–while limiting co-pays and beefing up benefits.

You might well ask: How can this be? How can we provide insurance for an additional 32 million people, improve Medicare, and simultaneously save money?

The media has not been a great help in answering these questions. This is, in large part, because the good news lies in the details—dozens and dozens of details. Fleshing out the myriad ways that the ACA generates new revenues while reining in health care spending would take up far too much time on a cable television show—and way too much space in most newspapers.

NCI’s Abdul Shaikh on Challenge for Enabling Community Use of Data for Cancer Prevention and Control

Oct 21, 2010• 2

Indu Subaiya, Director of the Health 2.0 Developer Challenge interviews Abdul Shaikh, Program Director for National Cancer Institute's Health Communication and Informatics Research Branch at NIH about the National Cancer Institute's inspiration in putting together the Enabling Community of Data for Cancer Prevention and Control challenge. Abdul talks about NCI's support of data mash-ups and visualizations related to cancer prevention and the need to create tools for both consumers and policy makers to utilize their data to drive behavior change, and draws inspiration from Hans Rosling's TED talk in 2006.

Interview with Abdul Shaikh

How Health Services Researchers Can Harness Data : Discussion at Health Innovation Week, SF

Oct 20, 2010• 3

By TED EYTAN, MD

Last week’s Health Innovation Week in San Francisco started for me with a day entitled “From Data to Information, to Knowledge to Application: How Health Services Research Can Harness Data to Help Support a More Rapid Learning Cycle,” at @KPGarfield in Oakland, California. I was asked to present an example from clinical practice on “Novel Means of Data Generation.”

Kind of a lot to get my head around as since I am not a health services researcher.

I knew that I would be co presenting with Gilles Frydman ( @gfry ) and as I have always learned, even if you don’t know what to do, take a good history, so I went.

The second in my slide is maybe a small reflection of my anxiety over Twitter, thanks to the audience for letting me express it.

Speaking of social media, I really liked the stated approach for the day, “share whatever you like, just don’t attribute it to people.” For me that sets a great tone, so kudos to the organizers for discussing this proactively rather than waiting for someone to ask. With that in mind, I will attribute things to myself only, since they’re my things to attribute…

The Politics of Health Reform

Oct 19, 2010• 44

By JOHN GOODMAN, PhD

There will be two national elections before the new health overhaul is substantially implemented (in 2014) and a third election the year it is supposed to be implemented.

Question: Will the voters reward office holders who supported the Affordable Care Act (ACA), or will they vote for their opponents? In thinking about this question, forget all the public opinion polls. Can you predict the outcome based on what you know about political science alone?

My prediction: Supporters of the new law are going to get creamed. As I explained at my own blog the other day, there are four reasons: The law violates two bedrock principles of coalition politics that have been successful for the past 80 years; it abandons core Democratic constituencies; and it ignores the fundamentals of the politics of the health care sector.

Franklin Roosevelt’s First Principle of Successful Coalition Politics: Create benefits for people who are concentrated and organized, paid for by people who are disbursed and disorganized.

The ACA violates this principle in spades. The main beneficiaries are many (but not all) of the new law are 32 million to 34 million newly insured people who otherwise would have been uninsured. Far from being organized and focused, most people in this group do not even know who they are. Indeed, it is probably fair to say that never in American history have so many benefits been conferred on so many people who never even asked for them!