The Health Care Blog – Page 790 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Accountability, Accountable Care Organizations, and Human Mindsets

Sep 22, 2010• 8

By KENT BOTTLES, MD

“Great companies have high cultures of accountability, it comes with this culture of criticism I was talking about before, and I think our culture is strong on that.” – Steve Ballmer

“I am responsible. Although I may not be able to prevent the worst from happening, I am responsible for my attitude toward the inevitable misfortunes that darken life. Bad things do happen; how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss, or I can choose to rise from the pain and treasure the most precious gift I have – life itself.”
– Walter Anderson

“When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else.” – David Brin

Accountable care organizations (ACOs) are all the rage as the perfect tool to achieve our most important goal in present day American health care: decreasing per-capita cost and increasing quality at the same time. Just this week I am presenting on ACOs at a law firm conference co-sponsored by two state hospital associations and the MGMA in Minneapolis and at a hospital system board retreat in Pennsylvania. Everybody wants to know how to implement ACOs.

An essential ingredient in ACOs is accountability, and yet human beings are not always comfortable with being held accountable. The two blog posts I wrote on physician report cards generated a lot of comments both in favor and opposed to personal accountability. And yet we know that hospitals and physicians are going to have to change the way they utilize medical resources if we are to indeed decrease per-capita cost and increase quality. Hospitals account for 40% of the rise in health care costs. Physicians account for only 20% of total health care expenditures, but when they treat patients they control the use of hospitals, drugs, medical devices, and laboratory tests.

If we are to control health care costs, hospital admissions will have to go down and physicians will have to order fewer and less expensive tests and treatments than they do today.

Profit-seeking Health Insurers Seek Profits

Sep 22, 2010• 20

DAVE DRANOVE
No one who sees this headline should read any further. There is no news here. So why is everyone getting lathered up about it? Let me explain.

Healthcare reform becomes official this week, as many of the provisions of the legislation kick in. One provision requires insurers to accept children with preexisting conditions while capping what they can charge, undoing a standard industry practice. Several insurers have indicated that they will stop selling child-only policies. Industry officials are having a field day criticizing insurance industry greed.

Maybe these officials haven’t noticed, but insurers are greedy and there is nothing anyone in the Obama administration can do about it. Maybe it needs repeating. Insurers are greedy, have always been greedy, and always will be greedy. So are all investor-owned companies. People don’t invest in health insurance companies (or any other investor-owned companies) for charity. They invest in them to make money. (Investors tend to be greedy too, and that includes the pension funds that most working Americans rely upon for their comfortable retirements.)Continue reading…

Risky Business

Sep 22, 2010• 15

By PAUL LEVY

At my annual physical exam last week, my primary care doctor employed a widely used web-based calculator to plug in cholesterol levels and other risk factors to estimate my likelihood of having a heart attack during the next ten years. I thought this was a neat idea until it produced an answer of 8%.

Wait, you mean I have a one in twelve risk of a heart attack over the next decade? That sounded really high. She calmly and thoughtfully explained that the main value of the algorithm was to help make a judgment about prescribing statins or other interventions that could lower risk. She also noted that anything under 10% at my age was a very good number.

So, I was going to write this post to tell this story and to make the point that these kinds of estimates can be shocking for the uninformed unless we have a context within which to interpret them.

I was also going to assert that the estimates give an impression of precision that may not be valid. What is the standard deviation around the estimate? How often is the actual estimate found to be true?Continue reading…

Live Health 2.0 Code-a-Thon at Google, Oct 2

Sep 21, 2010• 1

By Indu Subaiya & Matthew Holt

Health 2.0 is thrilled to announce the kick-off to Health Innovation Week: our first official code-a-thon where developers of all skill sets will get together, learn more about the vast amounts of health data that are available, build innovative health applications, and win prizes. The Health 2.0 Developer Challenge Code-a-thon will build on the existing online challenges, follow on from the Hacking4Health event on September 11, and introduce new datasets with some live on-site challenges.

Where & when?:

Saturday, October 2, 2010 — 9am – 8pm
Google Campus, Olympus Mons Room,
Building 1400 Crittendon,
Mountain View, CA

Confirmed speakers include:

Roni Zeiger, Chief Health Strategist, Google
Samantha Chui, Solutions Engineer and Mike Mee, API and PAT Product Manager, Keas
Sean Duffy and Zhen Zeng, IDEO
Walter Luh, CTO and interim CEO, Ansca Mobile….and more to come

But this not about sitting back and listening–it's about getting your hands dirty in the code and the data AND in a ground-breaking first for the Developer Challenge, we are pleased to announce that First DataBank will provide its drug databases free-of-charge to anyone developing applications – for any of the Challenges – that require content to support medication-related decisions and help improve patient safety and healthcare outcomes. You will want to take advantage of this unprecedented opportunity! More details on accessing this data will be announced soon.

This event is free to all–bring your laptop and ideas and we'll supply the pizza and jolt cola (or maybe something healthier). Come to the LIVE CODE page on health2challenge.org to sign up.

Mau-Mauing the Medical Loss Ratio

Sep 21, 2010• 18

By JOHN GRAHAM

Senator Max Baucus recently admitted that he never read the new health care law. But that hasn’t stopped him from trying to re-write it after the fact, in a way that would drive more health plans from the market and give consumers less choice.

The new law reduces choice of health plans by giving government the power to control the Medical Loss Ratio (MLR) — the amount of dollars an insurer spends on medical care divided by the total premiums. Policies that cover large businesses will have to achieve an MLR of 85 percent, while those for small businesses and individuals will have to achieve an MLR of 80 percent. This sounds simple but leaves many issues unresolved.

Calculating he MLR can be quite complicated — especially when the government gets involved. Suppose, for example, an insurer invests in information technology that it gives to patients or providers in its network in order to improve co-ordination of care. Is that a medical cost?

Furthermore, the MLR regulation is deadly for increasingly popular consumer-directed plans. Suppose a traditional policy costs $4,000 and spends $3,400 on patient care, for an MLR of 85.00. With the consumer-directed policy, the patient controls $800 more of the medical spending than with the traditional policy, through a higher deductible, and his premium goes down by $800. In this case the MLR goes down to 81.25 ($2,600/$3,200). There is no real difference, but the new regulation could require insurers to rebate $120 — the amount by which the ratio falls short of the required MLR. (In real life, the consumer-directed plan would have lower total costs than in this simple arithmetical example, because cutting out the middleman and giving more health dollars to patients to control themselves motivates them to get better value for money.)

Petitioners Ask OSHA to Regulate Resident Physician Work Hours

Sep 21, 2010• 17

By KATHERINE MATOS

On September 2, Assistant Secretary David Michaels for Occupational Safety and Health received a petition requesting that OSHA regulate resident physician and subspecialty resident physicians. “Depending on the type of residency, physicians-in-training can work anywhere from 60 to 100 or more hours a week, sometimes without a day off for two weeks or more.” The petition requests that OSHA exercise the authority granted under §3(8) of the Occupational Safety and Health Act to implement the following federal work-hour standard:

(1) A limit of 80 hours of work in each and every week, without averaging;

(2) A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians;

(3) At least one 24-hour period of time off work per week and one 48-hour period of time off work per month for a total of five days off work per month, without averaging;

(4) In-hospital on-call frequency no more than once every three nights, no averaging;

(5) A minimum of at least 10 hours off work after a day shift, and a minimum of 12 hours off after a night shift;

(6) A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts.

More information about the petition can be found at the Public Citizen-run website, WakeUpDoctor.org.Continue reading…

Diffusion of EHR Innovation

Sep 20, 2010• 5

By MARGALIT GUR-ARIE

No matter what your opinion of Electronic Health Records (EHR) is, you would probably agree that the concept of computerizing medical records represents an innovation of sorts. The spread of innovation, or its diffusion, has been researched and modeled by Rogers[1] as a bell shaped advancement through populations of Innovators, Early Adopters, Early Majority, Late Majority and Laggards (the blue curve in the figure below). At some point during this spread of an innovative solution a Critical Mass of adopters, or Tipping Point, is reached and the innovation is assured widespread diffusion (Gladwell[2]). Adoption is usually described by an S-shaped curve of adopters vs. time, and the rate of adoption is the slope of the S-shaped curve at any given time (the red curve in the figure).

The Tipping Point occurs right after the rate of adoption assumes its largest value which will be maintained throughout most of the adoption process. It is worth noting that the diffusion of innovation model is not predictive. Many innovations linger and die within the Innovator circle. Another important aspect of the model is that the time variable is not constrained. Depending on the rate of adoption, it may take weeks, months or many years for an Innovation to spread throughout a given population. There is no question that EHR adoption is slowly moving up on the ascending side of a classic diffusion model bell curve, but is it moving fast enough? Is the tipping point visible? Are we there yet?

Because it’s on the Interwebs, it must be true

Sep 20, 2010• 4

By Matthew Holt

Locally we’re supposed to diss the SF Weekly because it’s been trying to put the “genuine independent” local free weekly the SF Bay Guardian out of business and has lost a major lawsuit against it. But SF Weekly reporter Ashley Harrel has written an excellent article figuring out that one San Francisco plastic surgeon has paid a marketing company to plaster good reviews about her all over the web, and to make her the number 1 result on Google for “San Francisco Plastic Surgery”. The marketing agency unsubtly used the same name in all its reviews–the actual shortened version of the owner’s name–and has a video up on its site featuring the doctor as a happy client. Not exactly bright. Harrel also reminds us of the case of the chain plastic surgery center LifeStyle Lift that conducted a huge astroturfing operation and eventually settled with the NY Attorney General promising to stop.

Only one person on the San Francisco consumers bible Yelp seems to have noticed about this article but the person who died from a minor procedure hasn’t posted–although a few grumpy others have. (So apparently you either like this doctor or she kills you. My dad the surgeon always said he buried his mistakes!). And frankly that’s true for many patients and many doctors. In any event, the doctor is on probation from the state medical board–although that seems like a slap on the wrist.

The answer is twofold. First, get state medical boards to be more pro-active and aggressive in dealing with bad doctors. But realistically we know where that’s been going for years and its unlikely to change.

The second answer is to get better information in specialized places on the web, and elevate those.

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Sep 20, 2010

Vic Fuchs Speaks!

Sep 19, 2010• 14

By Matthew Holt

I was absolutely delighted that after several polite “maybe later” responses I was able to recently interview Victor Fuchs, the Henry J. Kaiser Professor Emeritus at Stanford University. Vic is best known as the “Father of Health Economics” and perhaps less well known (but more importantly to me!) the professor who taught the first health economics class that I ever took.

Matthew Holt: Victor, thanks so much for agreeing to come on THCB. I must admit Vic when I joined your class I had no idea about your background and reputation in health economics. So, I was just delighted to figure out that I blundered in right at the top. It’s a real pleasure to have you on the line

Victor Fuchs: I think you’re doing a great job and therefore I’m glad to spend some time with you.

Matthew Holt: Fantastic! You’ve, obviously, been observing and commenting on– and more recently sort of promoting ideas around –health reform for quite a while now, so let’s jump into a couple of things that you’ve published very recently, in fact just these past few weeks.

The first is a paper in The New England Journal of Medicine about a conceptual future for new biomedical innovation and I’d be grateful if you could just explain just a little bit what your general concepts are here. You’ve been working on this for quite a while. In fact, back when I was in your class, you were publishing some stuff with Alan Garber about technology assessment and this is sort of a continuation to that in some ways. So, I’d love to hear your thoughts.

Victor Fuchs: Well, I think there were two key elements here, one of them better understood by a larger audience and one of them I think rather new. Let me do the new one first. The new one is that we are going through what I call the second demographic transition.

The first transition was when every country had high mortality and high fertility and then the mortality especially of young people started to drop, but fertility did not drop right away, so you had a divergence there and in some cases it lasted for a couple of decades and during that time the population soared because there was this discrepancy between mortality and fertility.

You see the high fertility made sense when mortality was high because you wanted to have at least a couple of children survive to adulthood, but when mortality dropped it didn’t sink into people’s consciousness right away, so it took quite a bit of period which the historians and the demographers referred to as the demographic transition, okay. I don’t know if you’re familiar with it or not, but —

Matthew Holt: Yeah, I get the concept and there’s been some stuff written about that in terms of the impact on social security and healthcare.

Victor Fuchs: And some of the third world countries are going through it now, but now the second demographic transition is the one that I talk about in the NEJM piece a little bit. It has the following elements.

First is that a very large and increasingly large percentage of the population cohort lives until age 65, whereas at the beginning of the 20th century only a small percentage lived until 65. Now we’re going to 80% and we’ll eventually approach close to a 100% living till 65.

The second element is that life expectancy at 65 is increasing and it’s increasing at a quite brisk pace in recent decades. You put those two things together and you find out a very large and growing percentage of all the additional years that are lived if you have increasing life expectancy will be lived after 65.