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Above the Fold

What’s Your Platform?

Oct 15, 2010• 3

By JONATHAN BUSH

We’ve done some heavy dipping into the world of policy recently. In mid-September, I spent a day in Washington, D.C., with friend and advisor Tom Scully meeting researchers, senators, and a congressman. We heard from “ONCHIT” that “CCHIT”—which, as you know is an “ATCB”—granted us Stage 1 MU! This is great news for me, mostly because some competitors didn’t get it! (How’s that for starting a policy blog with some serious ABCs?!)

I met with some amazingly smart and engaged reporters who now (I think, get called “researchers,” since their newspapers can no longer afford them) work for the Henry J. Kaiser Family Foundation or NPR. They’re the real deal. They needed much less initial grounding in the problems we try to solve than most of the journalists we meet. They had taken on board the assumption that the move toward ACOs means less waste (which it could for some) and can get everybody in the clinical supply chain on one system (which has been seen to work at times).

But none of them appears to have considered the idea that there is a relationship between a healthy integrated health information ecosystem and a health information exchange marketplace. It’s still surprising to me, but precious few people correlate sustainability of any social good with the existence of a healthy marketplace with enough room for flexibility to allow innovation over time. It’s like the single economic condition responsible for ALMOST ALL of the social progress of this nation since inception, but in health care it’s still kind of a new idea.

Hospitalists as Extensivists

Oct 15, 2010• 5

By PAUL LEVY

I had heard something about this, but couldn’t find it. A colleague here finally tracked it down. The story is about Caremore, a California based organization. Hospitalists generally are internal medicine doctors based in the hospital; but here they care for frail elderly members at high risk of hospital admission or readmission in skilled nursing facilities and in outpatient settings both before and after a hospital stay. Here’s an article on the AHRQ Innovations Exchange website.

An excerpt:

A Medicare Advantage plan expanded the role of its employed hospitalists, using them to continue following and caring for recently discharged members until their condition stabilizes, as well as other members at high risk of a hospital admission. Known as “extensivists” and supported by sophisticated information technology (IT) systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and other members at high risk of an admission. Once or twice a week, these physicians also see members in SNFs.

The results:

The program reduced readmission rates and has led to low LOS (lengths of stay) and to below-average inpatient utilization in a high-acuity population.

Is this worth considering more broadly? What are the conditions for success? I welcome your thoughts.

Paul Levy is the President and CEO of Beth Israel Deconess 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.

NDM-1: Why Should the U.S. Care?

Oct 14, 2010• 3

By RAMANAN LAXMINARAYAN and HELLEN GELBAND

Why should the United States care about health problems in distant, poor countries when there are pressing priorities here at home? It’s a classic question. People trying to influence policy have never trusted humanitarianism to carry the day and have instead appealed to the self-interest of U.S. citizens. When it comes to health, U.S. travelers heading to foreign lands for tourism or work need protection from disease or at least the promise of a cure when they return home. Of utmost concern, the military sends large numbers of troops where they are in danger not only from armed conflict, but also from exotic (and often dangerous) diseases.

But no tropical disease can make as clear a case for U.S. self-interest as antibiotic resistance can: witness the furor over NDM-1—the resistance gene that seems to have arisen in patients on the Indian subcontinent. Was the furor over a health problem in India and Pakistan? No. The news that hit U.S. and European newspapers was over the report about NDM-1 in Lancet Infectious Diseases that identified people in England who had had surgery in India—“medical tourists”—as victims, and warned that the UK National Health Service might suffer financially because patients coming home had to be hospitalized and treated with expensive antibiotics to cure their infections. These just as easily could have been Americans—and now they are: NDM-1 was found in three U.S. medical tourists (and one Japanese man) on their return from India.

Care Coordination Metrics: One Can of Worms that NEEDS to be Opened

Oct 14, 2010

By VINCE KURAITIS

“Track who is on a care team — and share info with the patient.”

That’s just one of the summary recommendations coming from expert testimony given in a recent public hearing on how to improve care coordination through the use of health information technology. The Meaningful Use workgroup and Quality Measures workgroups are now wrestling with how to translate this recommendation into meaningful use criteria for HITECH Stages 2 and 3.

Seems like a good idea — simple, straightforward — perhaps even obvious. The EHR (electronic health record) could be a great tool for keeping care team members in the loop and on the same page about a patient’s care.

But then I thought about this for a few minutes, and the complexities started dawning. This seemingly simple recommendation — “Track who is on a care team and share info with the patient” — is the proverbial can of worms.

ACOs and the Looming Antitrust Crisis

Oct 14, 2010• 2

By DAVID DRANOVE

The Federal Trade Commission recently held a day-long workshop focusing on Accountable Care Organizations. ACOs will vertically integrate hospitals and doctors and, in the process, achieve what previous incarnations of vertical integration could not. Let’s forget about whether ACOs will actually fulfill the dream of efficient healthcare delivery and focus on the FTC angle – will the creation of ACOs require the creation of provider market power and should he FTC therefore look the other way?

Many health economists have documented the perils of provider market power. Some of my own research has been instrumental in turning the tide against providers, whose monopolizing tendencies used to get a free pass from the courts. But as policy makers move ACOs to the fore, providers are hoping to sweep antitrust under the rug.

The latest salvo comes from the AHA, which last week released a study challenging two recent studies of hospital market power and then strains to connect their findings to ACOs. The AHA report goes a bit overboard in its criticism of these studies. One study consists of little more than anecdotes and should not be criticized for being anything else. The other study is more complex and the criticism is equally complex, mostly along the lines of “if you had measured things slightly differently, your results would have been slightly different.” The AHA report would have readers believe that these two studies represent the entire body of knowledge about hospital mergers. Having summarily dismissed them, the argument against FTC enforcement would seem complete.

The True Health 2.0 Unmentionables

Oct 14, 2010• 3

By MICHAEL MILLENSON

At the recent Health 2.0 Conference, an unusual session highlighted the health importance of such “unmentionables” as job stress, marital worries and sexual dysfunction. However, despite the moderator’s inexplicable pride in a panelist’s mention of “vagina” – a topic certainly not lacking for Internet attention, albeit under more colloquial synonyms – the truly unmentionable subject was not sex, but the link between social class and health.

Unlike sex, talking openly about age and class distinctions makes most Americans squirm uncomfortably. Still, a number of speakers showed they understood that one of Health 2.0’s biggest challenges is proving itself useful to the population most in need of its help.

To start with, that means the elderly. Age brings an increased susceptibility to disease: half of Medicare beneficiaries are receiving care for one of six chronic conditions. Similarly, income is one of the most powerful predictors of health status. Those in the bottom 80 percent of adult income earners have an adjusted life expectancy almost 6 years shorter than those in the top 20 percent.

From that population perspective, two presentations stood out. The first was the partnership between Geisinger Health System and dLife. The second, for very different reasons, was the unveiling of Sharecare.

Republican Economics as Social Darwinism

Oct 14, 2010• 27

By ROBERT REICH

John Boehner, the Republican House leader who will become Speaker if Democrats lose control of the House in the upcoming midterms, recently offered his solution to the current economic crisis: “Liquidate labor, liquidate stocks, liquidate the farmer, liquidate real estate. It will purge the rottenness out of the system. People will work harder, lead a more moral life.”

Actually, those weren’t Boehner’s words. They were uttered by Herbert Hoover’s treasury secretary, millionaire industrialist Andrew Mellon, after the Great Crash of 1929.

But they might as well have been Boehner’s because Hoover’s and Mellon’s means of purging the rottenness was by doing exactly what Boehner and his colleagues are now calling for: shrink government, cut the federal deficit, reduce the national debt, and balance the budget.

And we all know what happened after 1929, at least until FDR reversed course.

San Francisco 2010: First Life Research at Health 2.0

Oct 14, 2010• 1

By Bianca Grogan

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.

Tugging on Superman’s Cape

Oct 12, 2010• 6

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

Oct 12, 2010• 14

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.