Doctor Visits as Data Points

The Patient Centered Research  Institute (PCORI)announced Tuesday how it would move forward on that mission: spend $68 million to fund a network of health-care systems that cover as many as 12 million patients. The idea is to use all the doctor visits that already happen — and all the treatments that doctors prescribe — to figure out which ones do best for a certain type of patient.
 

Sarah Kliff,  “Under Obamacare Program, doctor visits would become data points, “ Washington Post, April 23, 2012
 

In statistics, a data point is a set of measurements on a single member of a statistical population, or a subset of those measurements for a given individual. In addition, in statistical graphics, a "data point" may be an individual item with a statistical display; such points may relate to either a single member of a population or to a summary statistic calculated for a given subpopulation.

Data Point Definition

If you haven’t heard,  this is the age of Big Data.  The reasoning behind Big Data goes like this: Big Data is impersonal.  Big Data has no bias.  Big  Data is objective.  Big Data is easily collectiable.  Big Data is measurable. Therefore, Big Data is good.

Never mind that medicine is personal, confidential. subjective, and an Art.  With computers, artificial intelligence, and public funding,  medicine has become a  measurable, manageable Science.  Big Data is King.

Big Data  can now, and with precision,  define where we shop,  what we buy, when and where we buy, and who we elect. Big Data can  define what kind and the best of care we receive, and, ultimately, to what doctors  and hospitals we go. Those doctors and hospitals presumably will be the ones with the best outcomes and with no personal self-interests, income, or revenue axes  to grind.
 

Here is how the Washington Post explains the Obama administration's  Big Data program,

“The Affordable Care Act created the Patient Centered Research Outcomes Institute (PCORI) to support comparative effectiveness research, studies that identify the most effective treatments when a whole array of options might be available."

"PCORI announced Tuesday how it would move forward on that mission: spend $68 million to fund a network of health-care systems that cover as many as 12 million patients. The idea is to use all the doctor visits that already happen — and all the treatments that doctors prescribe — to figure out which ones do best for a certain type of patient.”

Two Big Obstacles with the Big Data Outcome Program – Patients and Doctors

At a recent meeting of 500 patients at which the program was explained and patients were asked if it would be OK if their data was used,  two patients raised their hand in affirmation and approval.

Doctors aren’t any happier with the idea.  In a local health system,  doctors are asked to wheel around or carry a laptop to enter patient data at the point of care, or “data point,” If you prefer. I am aware of two doctors who have left the system because they were uncomfortable with entering data in front of patients.  Said one to me, “I was trained to take care of people, not to being a computer technician and data entry clerk.”

Tweet:  Patients and doctors are uncomfortable with  using computers at the point of care to gather data on the efficacy of personal care and outcomes.

The Story of Obamacare Cost Inflation as Told to a Future Generation*

*Apologies to Henry Wadsworth Longfellow (1897-1882), Paul Revere’s Ride

Listen my children, and you shall hear, of  the drama,

Of the four year health inflation ride of Barack Obama,

On the twenty third of March twenty of twenty ten,

The Patient Protection and Affordable bill passed,

Without a single Republican vote caste.

Most of you are still alive it is clear I fear,

Who remember that infamous day and year,

When Obamacare passed with a cost now so dear.

The original cost was estimated for a decade at $900 billion,

Later revised by Congressional Business Office to $2.7 trillion,

A billion dollars here, a trillion dollars there,
What the hell, as long as all get their fair share.
Who could possibly object,
When cost was no object.

Still how could the estimate come to this,

With such a massive miscalculation miss?
When it contributed so much to the national debt,
That t left you and your children financially bereft.
Part of it was simply sleight of hand –  an artful  feint,
Delaying it until 2014 then to 2015 to avoid complaint.
Part of it was simply $716 billion ravings,
About ten year promises  of cost  savings,
Much of the estimate was purely theoretical,
But to challenge it was deemed heretical.

It was to be cchieved by cutting pay to hospitals and primary physicians,

Through accountable care organizations of hospitals and captive clinicians,

It was to be enforced by a 15-member Independent Payment Advisory Board.
Who would decapitate hospital and  doctors so the law we could afford.
But alas the IPAB,
May not come to be.
And when it comes time for the Feds theor  plan to implement,
State exchanges may not be ready for big government replacement.

Then five red state Democratic Senators like Max Baucus

Announced they were retiring, in effect leaving the blue caucus,

Would Obamacare be delayed or stranded,

Would its implementation be abandoned?

Please, please, do not be offended,

But I must leave you suspended.

I don’t know how the story ended.

Who's To Blame For Our Rising Healthcare Costs?

Preface:  Louis Goodman and Timothy Norbeck,  president and CEO, of the Physicians Foundation, wrote the following artilce in the April 2 issue of Forbes Magazine.  Readers might want to compare
their conclusions to mine, as expressed in today's Medinnovation blog post, "Who and What Drives Health Costs?"

"For many years and in countless articles, physicians have been the scapegoat for rising healthcare costs in the U.S. In fact, they have been blamed by many critics for the U.S. leading the world in healthcare expenditures.

A close examination of the data indicates that this blame is misplaced. Something else is revealed by digging deeper into the key components in healthcare spending: Technology, administrative expenses, hospital costs, lifestyle choice and chronic disease conditions have all had greater impacts on rising overall healthcare costs than physicians.

Some critics have suggested that physicians’ incomes and the fact that physicians direct most healthcare spending (80 percent is a frequently used number) are the real culprits in soaring healthcare costs. Yet despite this, physicians are not necessarily the principal beneficiaries of healthcare spending. The bulk of medical procedure payments go to hospitals and device manufactures. For example, in California, Medicare pays on average $18,000 for a total hip replacement – $16,336 to the hospital and $1,446 to the surgeon. This reimbursement disparity is certainly not limited to California, and is representative of a broader trend on a national level.

Moreover, doctors’ net take-home pay amounts to only about 10 percent of overall healthcare spending. Which if cut by 10 percent would save about $24 billion – a considerably modest savings when compared to the $360 billion spent annually for administrative costs as estimated by the Centers for Medicare & Medicaid Services (CMS), and the fact that 85 percent of excess administrative overhead can be attributed to the insurance system. Administrative costs for physicians are in the range of 25-30 percent of practice revenues and insurance-related costs are 15 percent of revenues, according to a National Academy of Social Insurance report for The Robert Wood Johnson Foundation.

Once the physician impact on healthcare costs is placed in proper perspective, the true role of other key factors can be examined more clearly.

The first area is technology. There is consensus among experts that technology is the most important driver of healthcare spending increases over time. Installing and implementing electronic health records is costly – often as much as $25,000 per doctor for a system and a monthly subscription fee on top of that – and requires significant resources.

A technical review panel convened to advise CMS on future healthcare costs trends concluded that about half of real health expenditure growth is attributable to medical technology. The Robert Wood Johnson Foundation goes on to say that advancing technology may have a particularly large impact on spending in the U.S. because of “few requirements that effectiveness be demonstrated before technologies are used broadly and concern that their application tends to go beyond those patients likely to benefit the most from them.

Administrative  expenses and hospital costs represent two additional areas of significant concern. Physicians are continually frustrated as they see increasing administrative regulations as significant burdens that take away from patient care, and they are deeply pessimistic as they struggle to sustain their practices. Seventy-seven percent of physicians feel negatively about the future of medicine, according to the Foundation’s survey of more than 13,500 physicians. Many independent practicing physicians are seeking employment at larger hospital systems to avoid administrative burdens. Forty percent of primary care physicians today who see patients at hospitals are employed by the hospital, which has doubled since 2000.

But hospitals may not be the solution for lowering healthcare costs in the United States.

Hospital costs during 2010 in the U.S. constituted $814 billion or 31.4 percent of all healthcare expenditures. Furthermore, the cost of care will only continue to rise as we shift into a consolidated healthcare system and programs like Medicare allow higher payments for services performed in hospitals as opposed to independent private practices. One widely reported example found a Nevada patient whose echocardiogram bill came to $373 before the physicians’ practice had been purchased by a hospital system and then increased to $1,605 after the merger.

Finally, another vital factor to consider is that of life style and chronic conditions. Chronic diseases are the most common and costly of all health problems, but they are also the most preventable. According to the CDC’s National Center for Chronic Disease Prevention and Health Promotion, our common, health-damaging but modifiable behaviors – tobacco use, insufficient physical activity, poor eating habits, and excessive alcohol use –are responsible for much of the illness, disability and premature death related to chronic disease. And people with three or more chronic disease conditions generally fall into the costliest one percent of patients who account for 20 percent of all healthcare spending in the U.S.

Moreover, there is a real issue of health disparities that exists in this country leading to higher healthcare costs. Between 2003 and 2006, the Joint Center for Political and Economic Studies estimated the total direct and indirect costs of health inequities affecting racial and ethnic minority populations, including lost wages and productivity – exceeded $1.2 trillion.

Clearly, to achieve true cost savings in our healthcare system, experts must look at all of these factors that are driving healthcare costs above the gross domestic product, population growth and inflation – and recognize that the literature and data simply do not point to physicians as a primary or even secondary cause of rising healthcare costs. Physicians have been a target of blame for many years, but the facts about what drives healthcare costs indicate otherwise."

Tweet:   Technology,  administrative,  hospital, lifestyles, and chronic diseases, not physician expense,  are driving health costs.

Who and What Drives Health Costs?

Ask the right question to find the right answer.

Peter F. Drucker (1909-2005)

Is it specialists? After all, they order the tests and perform the procedures that drive up costs.  They admit patients to hospitals,  where true high costs lie.  They self-refer to imaging centers and specialty centers they own.   They accept speaking fees from drug and device companies to promote products. Yet you never hear the expression “Specialist-Driven Health Care.” Why? Because the public likes  specialists.

Is it the specialists-primary care mix?  After all, unlike most other nations, whose costs are half ours.  Two thirds of our doctors are specialists.   Everybody knows in nations where most doctors practice primary care, costs are lower.  Is it combination of both, since neither specialits or primary care doctors often know the cost of the procedures or drugs they prescribe? Or is it simply the “fragmented system,” where one doctor does not what the other is doing, who lack “coordination,”  who order duplicate tests?

Is it the trial lawyers who force doctors to practice “defensive medicine,”  by ordering every test and performing every procedure to avoid the feared question from a malpractice attorney,”Why didn’t you do this or that, doctor?”

Is it the hospitals? After all,  hospitals  house marketing departments that lure patients to hospitals where the high-cost, high tech, sometimes robotic surgical  care is delivered?  Their most profitable “product lines” are driven by orthopedic surgeons,  cardiovascular,  oncology, other surgical, and imaging  specialists. For every dollar spent there, 90 cents goes to the hospital, only 10 cents to the doctor.

It is  health plans?  After all, they  cover some 200 million Americans, and they set the fees and pay for the care.  Surely they should share some of the blame for the administrative costs of care, which represents 25% of all health costs.

Is it government?  After all,  government accounts for 50% of health costs,  and government, in concert with the AMA and RUC (Reimbursement Update Committee)  sets the codes by which physicians are paid.   Or is government the answer?  Costs are lower in countries with government-controlled care.  Still,  no one talks of government-driven care?  Why not?  Because that would smack of “socialized medicine,” whick the majority of Americans abhor.  Trouble is,  of course, premiums are doubling under Obamacare and individual markets are beginning to suffer “sticker shock.” No, more government is not the solution.

Is it “market-driven”  health care?  After all, everybody knows markets are fickle and uneven and reward those with enough money to afford care.  One way to reign in markets, of course, if for government to act and pass a health reform law “The Patient Protection and Affordability Act.” 

Finally, is “consumer-driven care” the problem?   After all,  Medicare patients with chronic disease go to six or seven specialists each year.   Besides,  because of the entitlement mentality and comprehensive coverage by third parties,  consumers do not know the true costs of care, and why should they? They do not pay bills out of their own pockets.

According to Regina Herzlinger,  a tenured professor at Harvard Business School,   consumers may be the answer – not the problem . In a series to classic books – Market-Driven Health Care (1997), Consumer-Driven Health Care (2004), and Who Killed Health Care? (2007), she explains  consumer hold the key to a rational health system.  She identifies the “killers” of the system as the dysfunctional health plans,  empire-building hospitals,  “one choice” employers,  congressional control by our elected politicians,  and our academic “elite policy makers.”  

Her answer?  Let medical business entrepreurialism  bloom,  let information flow.  And here is her formula for bold laws that make consumer-driven care happen for the benefit of all.

1)      Require everyone to buy his or her own insurance, using tax-sheltered income.

2)      Have government help those who cannot afford to buy health insurance by subsidizing them.

3)      Allow providers to bundle care as they want to and to quote their own prices.

4)      Have government require publication of data on the performance of all providers.

5)      Risk adjust all prices- the sick account for the bulk of health costs; make covering them in a cost-effective fashion attractive financially.

Tweet:   Consumer-driven care, in which consumers and physicians have “skin in the game” and are sensitive to costs, will lower health costs.

Thoughts on Singapore Health System

 Even in a society as tightly controlled as Singapore’s, the market creates certain forces which perhaps in the long run may lead to democracy.
 

 Peter L. Berger (born 1929), American sociologist who specializes in the structure of societies.

 

I recently briefly  chatted with Paul Grundy, global director of IBM global health, who had just returned from Singapore, where he had once lived for 3 years.  We did not discuss Singapore’s health system, but subsequently I ran across this description of the system.

 “The Singapore Health Care system costs in Singapore costs less than 25% of that in the USA and results are better. In Singapore everyone has 6-8% deducted from your income for a Medicate account that is used for hospitalized medical expenses. The government subsidizes the health care system but the system is based significantly on the consumers paying (from their Medicate account or cash) and therefore making economic decisions.”
 

 “The medical system in Singapore has been designed with much more attention to costs than the USA system. Hip replacement costs US $43, 00 in the USA and US, $12,000 in Singapore. A heart bypass costs US $127,000 in the USA versus US $22,500 in Singapore.”
 

 “The quality of Singapore health care is at the highest level worldwide. There is health insurance available in Singapore though many rely just on the Medisave accounts. Catastrophic  health care coverage is widely used.”
 

This got me to thinking:

How do Singaporeans do it? 

Apparently they rely on a national  public system where most get their care.   But  authorities allow patients to use the private system as much as they wish and practitioners to charge what  they wish as long as consumers use their own money out-of-pocket and out of their medical savings accounts.   The Singaporeans have three interdigitating systems: Medischield, Medisavings, and Mediservices, -the interrelationships which I do not fully understand.
 

 But as understand it, the responsibility and decision making rests with consumers.    It sounds as if  Singapore has a universal version or our health savings accounts, except we restrict consumers from setting aside more than $2500 in any given year   The average citizen of Singapore now makes $50, 000 a year, which means they can stash away $3000 to $4000 yearly, and if cumulative savings are not enough, catastrophic coverage kicks in. 
 

 Comparisons between countries with different cultures, especially a Pacific Island or 5 million or so. predominately ethically Chinese , to  a continental nation of 315 million, is a dicey proposition, but there are perhaps lessons to be learned.
 

 As I was pondering the comparisons,  I ran across the review of a book by Lee Kwan Yew, “The Grand Master’s Insight on China, the United  States,  and  the World. “ Yew, now 89, was Singapore’s  leader from 1959 to last year, when he stepped down and during his reign  per capital income in Singapore rose from $400 to $50,000.  
 

 Yew’ s advice  to America, whom he considers a staunch ally. Keep your culture. You are creative, inventive, and original.  You have a capacity for renewal and revival.   Retain your openness.  Invite people from abroad to work with you and for you. Keep your “can do” spirit.  Realize risk and failure go together.  Do not go the way of Europe with its entitlement mentality and massive welfare states.  Be entrepreneurial.   Don’t  let the mass media, and  preoccupation with guns, violence, and social inequality  lead you astray. Control your debt,. Exploit your human capital, emphasize your assets, not your liabilities, and control your debt.

 

Tweet:  Singapore, an island of 5 million, has a health system that offers universal coverage that costs less than 25% of the US per capita.

                                                                                           

Doctors: Out with the Old and Realistic, In with the New and Idealistic

What is morality at any time or place? It is what the majority then and there happen to like, and immorality is what they dislike.

Alfred North Whitehead (1861-1947), Dialogues of Alfred North Whitehead

Reading the health reform tea leaves is a little like reading a morality play.   A morality play’s main theme is this: We begin in innocence.We falls into temptation. We repent and are savedl  We struggle against the seven deadly sins of greed and self-interest.  

Some argue that fee-for-service impels doctors to become specialists, to master a narrow discipline, to do as many procedures as possible out of greed, and to do everything to pursue their own interests rather than those of patients.  

The answer to reforming these misdireactions,  believe, medical school educators,  is to reform how doctors think by picking a different kind of medical student and reeducating them to meet society's interests and those  patients rather than their own needs.

This point of view is expressed in three articles in the April 25 New England Journal of Medicine.  The articles, by medical school academics from Boston University, Icahn School of Medicine at Mount Sinai in New York, and University of California in Los Angeles, accurately reflect their content.

·         “Holistic Review- Shaping the Medical Profession One Applicant at a Time.”

·         “Reforming Premedical Education – Out with the Old, In with the New”

·         “The Opportunities and Challenges of a Lifelong Health System.”
 

The gist of these articles is that we need to create a new kind of doctor and to minimize producing the old kind of doctors - those overly structured, driven individuals who sought to master medical and specialized subject matter – and to select a new kind of doctor – a holistic generalist team who works well on a salary within organizations and who knows as much about humankind than his or her own self-interest and discipline.

The result, say the various authors,  is “that medical school admissions  is not merely about selecting new year’s class, but also about selecting the physicians who will successfully lead a rapidly evolving 21^st-century health care workforce… we have allowed premedical curricula to ossify despite advances in science , clinical practice and technology…The main challenge it to create a lifelong health system lies in moving from a fee-for-service model with  short time frames in paying for value and better outcomes over the long term. Innovation in care delivery, integration of services, and development and adaption to new fiscal tools can all contribute to strategies for improving health.””

I’m reminded of comments by Phillip Miller of Merritt Hawkins, a national physician recruiting firm.

“Students still go into medicine for the right reasons - to take care of people and to create the bond of the physician-patient relationship.  ...The difficulty arises once they have gone through all those years of training and begin practice.  They find the medical practice environment interrupts their dreams and disrupts patient relationships. At that point, physicians become disaffected, more so than they have in the past.”

Which brings me to what many older doctors think?   Jeffrey Singer, MD, a Phoenix based surgeon, writes in the current issue of Reason magazine

“Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.”

Tweet: Medical schools are now selecting and creating a new kind of doctor- team-based, less-structured physician intent of improving outcomes.