Big Doctoring in America
The time comes in the life of even the most dedicated logger to admit that someone has said what needs to be said better than you can. Such is the case with Fitzhugh Mullen, MD, practicing pediatrician in inner city Washington, D.C, professor of pediatrics at George Washington University, and contributing editor to Health Affairs.
Here is his take on primary care (Big Doctoring in America: Profiles in Primary Care,” University of California Press, 2002).
The rationale for building the base of primary care in this country is compelling. While many Americans like their doctors and are proud of the scientific progress of the medical system, there is current dissatisfaction with the system as a whole and a realization that its considerable cost does not match up with its more modest outcomes. Many realize that our system is exceedingly expensive, lavish in its use of technology, and undistinguished in its results. ..By most measures, we have an enormously top-heavy, procedure-prone system dominated by a specialty model of care with relatively little investment in primary care. This system consumes an ever-expanding portion of our gross national product, increasingly competing with every other economic interest, personal and public. The health care reform movement in the early 1990s took on this problem but failed. The offensive of the late 1990s, touted at the “market solution” to this same conundrum, has not worked either, affronting patients and physicians alike and controlling costs only briefly. And innovation – new pharmaceuticals, diagnostic devices, and treatments – seem only to complicate the decisions that are necessary to craft a system that uses our science effectively, satisfies patients, and is fair.
Primary care built on the broad based of generalism, as practiced by big doctors, offers the basis for a reconceptualized, rebalanced system of health care in America that move us beyond the expensive and dispiriting medical swamp that we have found ourselves in recent years. Towards that end, I offer the following thoughts on the future, a gentle manifesto for the role that primary care can ply in improving American health.
Two characteristics of our health care future seem predictable, since they are obvious extrapolations of powerful current trends, continued technological innovation and the ubiquity of information. Together they are going to affect medicine in ways that will underscore the importance of the generalist approach to health care
Saturday, August 30, 2008
Wednesday, August 27, 2008
Medical megatrends - The Great Disconnect: Altitudes and Attitudes in Politics and Health Reform
In the course of my work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society, that is, where new trends and ideas begin in cities and small communities, not New York City or Washington, D.C. My colleagues and I have studied this great country by reading the local newspapers. We have discovered trends are generated from the bottom-up, fads from the top-down.
John Naisbtt, Megatrends: Ten New Directions Transforming Our Lives, 1980
I admire the writings of futurist John Naisbitt, in Megatrends (1980) and Mindset! (2007), for Naisbitt understands, more than anyone I know, the importance of altitudes and attitudes.
In discussing the politics of health care, it is crucial to understand altitudes, as seen from above, and attitudes, as viewed from the grassroots, for the two are inextricably intertwined. Nowhere is this more evident than in health care.
If you start from a top-down altitude, whether that be in Washington, D.C, the rarified heights of a think-tank, or a command-and-control corporate or helaht plan board rooms, you have a certain mindset, that you know best what should be done at the grassroots. It is an easy trap to fall into, for you command the heights of decision-making, for that is what you are paid to do, and you either pay the bills or advise those who do.
Consider those who control national health and corporate health policies. In 1965, America decided Medicare and Medicaid officials would henceforth know best what was good for the old, the poor, and the disabled. Roughly ten years later, managed care started in earnest, and business payers decided that health care decision-making in the streets, hospitals, doctors offices, and other myriad care locations was too important to be left to patients and doctors.
In all of these setting, the altitude dictates the attitude- the mindset of the powers that be. To a large extent, these altitudes and attitudes are understandable. For every social tasske of importance is entrusted to large institutions organized for perpetuity and run by political leaders and managers. But we are an individualist society, dominated by pluralistic forces. And as time has passed, patients, as well as physicians, have become increasingly critical , disenchanted, and suspicious of the ability to top-down powers to perform, to understand what is transpiring on the ground, and to use tools such as information technologies, to control and guide what wells up from below.
The consequences of these differing views from different altitudes and attitudes has been a giant disconnect –a yawning chasm between those above who profess to know and those who practice below.
Take managed care as an example. Those who profess to know first thought costs could be controlled and channeled by restricting utilizations and dampening referrals to specialists and hospitals. This set of attitudes has been a colossal failure because of a misunderstanding of American culture. Now those who profess to know have changed course and have decided the best way to control costs and better care lies in concentrating and coordinating course is through primary care offices and through offering small rewards for “performance.” Small wonder, given the track record of managed care, that doctors harbor dark suspicions that this too may not work.
It does not seem to have dawned on top-down decision-makers that that the primary care professions, due to a series of missteps from above – burdensome and expense-producing rules and regulations requiring large office staffs, misguided reimbursements, over-reliance on high tech, a worship of data, and a lack of respect – has thrown the primary care professions into total disarray, indeed on verge of destruction, because primary care no longer appeals to pragmatic struggling doctors.
Nor has the idea seem to set in that doctors, as members of a profession, do not respond to small financial incentives to perform higher quality care. For God’s sake, they say, that is what we are obligated to do in the first place. And neither do we respond to giant check lists sent down from above to tell us how to manage patients, or to anguished cries of uneven “quality,” as defined by payers sending down proclamations. We are doctors, not airline pilots, and we march to our own drummer – what’s good for the patients.
Doctors want understanding of what top-down meddling has wrought – overworked physicians, overcrowded offices, misguided reimbursements, over-written rules that often serve no useful purpose, incentives that don’t incent and may even dis-incent, and over-engineered medical record systems that are neither patient or doctor friendly.
John Naisbtt, Megatrends: Ten New Directions Transforming Our Lives, 1980
I admire the writings of futurist John Naisbitt, in Megatrends (1980) and Mindset! (2007), for Naisbitt understands, more than anyone I know, the importance of altitudes and attitudes.
In discussing the politics of health care, it is crucial to understand altitudes, as seen from above, and attitudes, as viewed from the grassroots, for the two are inextricably intertwined. Nowhere is this more evident than in health care.
If you start from a top-down altitude, whether that be in Washington, D.C, the rarified heights of a think-tank, or a command-and-control corporate or helaht plan board rooms, you have a certain mindset, that you know best what should be done at the grassroots. It is an easy trap to fall into, for you command the heights of decision-making, for that is what you are paid to do, and you either pay the bills or advise those who do.
Consider those who control national health and corporate health policies. In 1965, America decided Medicare and Medicaid officials would henceforth know best what was good for the old, the poor, and the disabled. Roughly ten years later, managed care started in earnest, and business payers decided that health care decision-making in the streets, hospitals, doctors offices, and other myriad care locations was too important to be left to patients and doctors.
In all of these setting, the altitude dictates the attitude- the mindset of the powers that be. To a large extent, these altitudes and attitudes are understandable. For every social tasske of importance is entrusted to large institutions organized for perpetuity and run by political leaders and managers. But we are an individualist society, dominated by pluralistic forces. And as time has passed, patients, as well as physicians, have become increasingly critical , disenchanted, and suspicious of the ability to top-down powers to perform, to understand what is transpiring on the ground, and to use tools such as information technologies, to control and guide what wells up from below.
The consequences of these differing views from different altitudes and attitudes has been a giant disconnect –a yawning chasm between those above who profess to know and those who practice below.
Take managed care as an example. Those who profess to know first thought costs could be controlled and channeled by restricting utilizations and dampening referrals to specialists and hospitals. This set of attitudes has been a colossal failure because of a misunderstanding of American culture. Now those who profess to know have changed course and have decided the best way to control costs and better care lies in concentrating and coordinating course is through primary care offices and through offering small rewards for “performance.” Small wonder, given the track record of managed care, that doctors harbor dark suspicions that this too may not work.
It does not seem to have dawned on top-down decision-makers that that the primary care professions, due to a series of missteps from above – burdensome and expense-producing rules and regulations requiring large office staffs, misguided reimbursements, over-reliance on high tech, a worship of data, and a lack of respect – has thrown the primary care professions into total disarray, indeed on verge of destruction, because primary care no longer appeals to pragmatic struggling doctors.
Nor has the idea seem to set in that doctors, as members of a profession, do not respond to small financial incentives to perform higher quality care. For God’s sake, they say, that is what we are obligated to do in the first place. And neither do we respond to giant check lists sent down from above to tell us how to manage patients, or to anguished cries of uneven “quality,” as defined by payers sending down proclamations. We are doctors, not airline pilots, and we march to our own drummer – what’s good for the patients.
Doctors want understanding of what top-down meddling has wrought – overworked physicians, overcrowded offices, misguided reimbursements, over-written rules that often serve no useful purpose, incentives that don’t incent and may even dis-incent, and over-engineered medical record systems that are neither patient or doctor friendly.
Sunday, August 24, 2008
Physician Culture, Physician Demoralization - Twelve Physician Sensibilities
The capacity to feel or perceive: the capacity to respond emotionally or aesthetically.
Sensibility, Dictionary definition
The average physician perspective is this. I went to medical school I’m loaded with debt. I’ve got an office full of people pushing paper every day. I don’t have time to talk to anybody. Nobody in Washington seems to care what I think. I can’t function this way. I don’t egt reimbursed enough.
Arthur Caplan, PhD, Professor of Bioethics at the University of Pennsylvania, “Shattuck Lecture: Health of the Nation” Coverage of All Americans, “ New England Journal of Medicine. August 21, 2008
Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.
Michael S. Barr, MD, MBA, VP, Patient Advisory and Improvement, American College of Physicians, “The Need to Test the Patient-Centered Medical Home, “ JAMA, August 20, 2008.
People tell me I clearly grasp physician sensibilities. That may or may not be true. You be the judge.
Sensibility One - The public and policy makers have little understanding of the depth and breadth of physician demoralization and dissatisfaction, particularly among primary care clinicians. This misconception may be remedied soon by a survey of 300,000 primary care physicians by the Foundation of Health System Excellence, a nonprofit organization representing state and local medical societies. The survey covers physician attitudes, levels of satisfaction, socioeconomic status, and state of U.S. health care.
Sensibility Two – Physicians are either not entering or fleeing primary care in record numbers. This will soon lead, if it has not already, a widespread primary care shortage and will precipitate an access crisis.
Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless with access to primary care physicians, a problem now manifest and playing out in Massachusetts, and beginning to be addressed by policy makers and members of the medical academic establishmment.
Sensibility Four – Dissatisfaction with care is rampant among primary care physicians, who yearn to spend more time with patients and to bet off the current productive line practices, requiring them to see 20 to 30 patients a day. Much of this unhappiness stems from a reimbursement system that rewards high-tech procedures rather than cognitive care and time spent with patients.
Sensibility Five - The reimbursement system falls to pay physicians for such vital things as same-day appointments, and telephone and email consultations. In the case of telephone calls, this is absurd since many physicians spend at much as ¼ to 1/3 of their time on the phone.
Sensibility Six - A growing and unknown number of primary care physicians are opting out of HMOs, PPOs, and other third party arrangements, seeking refuge in concierge and cash-only practices to escape the harassment and overheads involved in dealing with third parties.
Sensibility Seven - Malpractice fears reap havoc, both psychologically and economically, because it engenders mutual distrust and fosters defensive medicine to avoid future malpractice actions, while doing little to protect patients against harm..
Sensibility Eight - Medicare and other federal programs, because of their size, scope, impersonal, and bureaucratic nature, are recipes for fraud and abuse. Scam artists – and rarely opportunistic patients, doctors, hospitals, and entrepreneurs – often “game” the system, resulting, among other things, in vast overruns in Durable Medical Equipment businesses.
Sensibility Nine - Many physicians instinctively distrust information technologies as instruments for savings and safety because they tend to benefit health plans and because of high costs of installation, training, maintaining, practice disruptions, low returns on investment, limitations in communicating with colleagues and hospitals, and their secret suspicion that these technologies may serve as vehicles for monitoring, punishing non-compliance, rating doctors, and excluding doctors.
Sensibility Ten - The potential value of virtual e-medicine in treating and consulting with patients over the Web rather than seeing them face-to-face is squandered and is often meaningless because Medicare and most health plans do not pay for virtual visits.
Sensibility Eleven - The savings of prevention, with the exception of smoking cessation, may be over-estimated because physicians are not paid for counseling patients, many patients do not like to be lectured on life style, and many resume harmful behaviors after they leave the doctor’s office or hospital. Besides preventing disease, though it saves money in the short run, may cost more in the long run because of costs of treating the elderly.
Sensibility Twelve – The Medical Home concept, is laudable because it places patients and primary care doctors at the center of coordinated care. Current pilot studies should be continued, but doctors fear the process has become too “political” and too bureaucratic. Doctors are acutely aware of the tremendous investment in information infrastructure and staff required and uncertainly of rules and rewards entailed.
Sensibility, Dictionary definition
The average physician perspective is this. I went to medical school I’m loaded with debt. I’ve got an office full of people pushing paper every day. I don’t have time to talk to anybody. Nobody in Washington seems to care what I think. I can’t function this way. I don’t egt reimbursed enough.
Arthur Caplan, PhD, Professor of Bioethics at the University of Pennsylvania, “Shattuck Lecture: Health of the Nation” Coverage of All Americans, “ New England Journal of Medicine. August 21, 2008
Research suggests that the presence and support of a robust primary care system is a major characteristic of an efficient and high-quality health care delivery. However, the future of the US primary care system is uncertain at best and is perilously close to collapse at worst. Fewer medical students and residents are choosing primary care specialties, and physicians in practice are leaving internal medicine faster than their other colleagues with a subspecialty.
Michael S. Barr, MD, MBA, VP, Patient Advisory and Improvement, American College of Physicians, “The Need to Test the Patient-Centered Medical Home, “ JAMA, August 20, 2008.
People tell me I clearly grasp physician sensibilities. That may or may not be true. You be the judge.
Sensibility One - The public and policy makers have little understanding of the depth and breadth of physician demoralization and dissatisfaction, particularly among primary care clinicians. This misconception may be remedied soon by a survey of 300,000 primary care physicians by the Foundation of Health System Excellence, a nonprofit organization representing state and local medical societies. The survey covers physician attitudes, levels of satisfaction, socioeconomic status, and state of U.S. health care.
Sensibility Two – Physicians are either not entering or fleeing primary care in record numbers. This will soon lead, if it has not already, a widespread primary care shortage and will precipitate an access crisis.
Sensibility Three – Universal coverage and comprehensive coordinated care is meaningless with access to primary care physicians, a problem now manifest and playing out in Massachusetts, and beginning to be addressed by policy makers and members of the medical academic establishmment.
Sensibility Four – Dissatisfaction with care is rampant among primary care physicians, who yearn to spend more time with patients and to bet off the current productive line practices, requiring them to see 20 to 30 patients a day. Much of this unhappiness stems from a reimbursement system that rewards high-tech procedures rather than cognitive care and time spent with patients.
Sensibility Five - The reimbursement system falls to pay physicians for such vital things as same-day appointments, and telephone and email consultations. In the case of telephone calls, this is absurd since many physicians spend at much as ¼ to 1/3 of their time on the phone.
Sensibility Six - A growing and unknown number of primary care physicians are opting out of HMOs, PPOs, and other third party arrangements, seeking refuge in concierge and cash-only practices to escape the harassment and overheads involved in dealing with third parties.
Sensibility Seven - Malpractice fears reap havoc, both psychologically and economically, because it engenders mutual distrust and fosters defensive medicine to avoid future malpractice actions, while doing little to protect patients against harm..
Sensibility Eight - Medicare and other federal programs, because of their size, scope, impersonal, and bureaucratic nature, are recipes for fraud and abuse. Scam artists – and rarely opportunistic patients, doctors, hospitals, and entrepreneurs – often “game” the system, resulting, among other things, in vast overruns in Durable Medical Equipment businesses.
Sensibility Nine - Many physicians instinctively distrust information technologies as instruments for savings and safety because they tend to benefit health plans and because of high costs of installation, training, maintaining, practice disruptions, low returns on investment, limitations in communicating with colleagues and hospitals, and their secret suspicion that these technologies may serve as vehicles for monitoring, punishing non-compliance, rating doctors, and excluding doctors.
Sensibility Ten - The potential value of virtual e-medicine in treating and consulting with patients over the Web rather than seeing them face-to-face is squandered and is often meaningless because Medicare and most health plans do not pay for virtual visits.
Sensibility Eleven - The savings of prevention, with the exception of smoking cessation, may be over-estimated because physicians are not paid for counseling patients, many patients do not like to be lectured on life style, and many resume harmful behaviors after they leave the doctor’s office or hospital. Besides preventing disease, though it saves money in the short run, may cost more in the long run because of costs of treating the elderly.
Sensibility Twelve – The Medical Home concept, is laudable because it places patients and primary care doctors at the center of coordinated care. Current pilot studies should be continued, but doctors fear the process has become too “political” and too bureaucratic. Doctors are acutely aware of the tremendous investment in information infrastructure and staff required and uncertainly of rules and rewards entailed.
Friday, August 22, 2008
Primary care - A "Personal" Physician Speaks, everything's in the name
A “Personal Physician” Speaks, Everything's in the Name
There is no other profession as personal as the medical profession. It physicians continue to allow non-physicians and businesses such as hospitals and insurers to control them, they will lose their patients and will nothing more than over-educated technicians.
Donald Copeland, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, (Jones and Bartlett, 2007)
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Yesterday I was speaking to Don Copeland, a friend and a family physician, in North Carolina. My wife says of Don, “When I get sick, Dick, I want Don as my personal doctor.” Don is a fine physician, beloved by patients. He takes their best interests to heart and acts accordingly.
A “personal physician” is exactly what Don considers himself to be – nothing more, nothing less. He thinks of a personal physician as a personal guide, confidante, and trusted advisor. He thinks of the personal physician-patient relationship as a spiritual bond, best left untouched and untouchable by remote third parties.
Don insists the very terms, “primary care physician” and “provider” are misnomers. The proper designation ought to be “personal physician.” Don is equally disdainful of the adjecti ve “cognitive” and “proceduralist” as applied to personal physicians. A personal physician, after all, may perform procedures in the office, sparing his patients the inconvenience, expensive, delays, and paperwork involved in needless referrals.
Besides, any physician, not matter what he is named or how he is characterized, ought to have the liberty to charge directly for his services, which is the reason, Don champions health savings accounts. Don even has visions of starting a national HSA organization in collaboration with community banks.
Don maintains, and rightly so, that doctors and patients lie at the very core of the health system. Government bureaucrats , health plan executives, and hospital leaders are secondary players, who depend on doctors. Somehow, in the process of labeling doctors as “primary” and “provider,” these players have over-played their hands, and reduced a noble profession to a dec idedly impersonal business.
It may take a while for these big players to see the error of their ways. Unitl then, I'm reminded of a Casey Stengel tale. After managing the world champion Yankees, Casey managed the lowly Mets. Marv Thornberry was one of his hapless crew. Casey was disgusted with Marv's playing and decided to show him how things were done. Casey took to the field, had a fungo fly hit to him -- and dropped the ball. He turned to Thornberry and shouted, "Marv, you've got this position so fowled up, nobody can play it!" The same may hold true for payers who have placed physicians on the field of play as quasi-employees.
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There is no other profession as personal as the medical profession. It physicians continue to allow non-physicians and businesses such as hospitals and insurers to control them, they will lose their patients and will nothing more than over-educated technicians.
Donald Copeland, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, (Jones and Bartlett, 2007)
< o:p>
Yesterday I was speaking to Don Copeland, a friend and a family physician, in North Carolina. My wife says of Don, “When I get sick, Dick, I want Don as my personal doctor.” Don is a fine physician, beloved by patients. He takes their best interests to heart and acts accordingly.
A “personal physician” is exactly what Don considers himself to be – nothing more, nothing less. He thinks of a personal physician as a personal guide, confidante, and trusted advisor. He thinks of the personal physician-patient relationship as a spiritual bond, best left untouched and untouchable by remote third parties.
Don insists the very terms, “primary care physician” and “provider” are misnomers. The proper designation ought to be “personal physician.” Don is equally disdainful of the adjecti ve “cognitive” and “proceduralist” as applied to personal physicians. A personal physician, after all, may perform procedures in the office, sparing his patients the inconvenience, expensive, delays, and paperwork involved in needless referrals.
Besides, any physician, not matter what he is named or how he is characterized, ought to have the liberty to charge directly for his services, which is the reason, Don champions health savings accounts. Don even has visions of starting a national HSA organization in collaboration with community banks.
Don maintains, and rightly so, that doctors and patients lie at the very core of the health system. Government bureaucrats , health plan executives, and hospital leaders are secondary players, who depend on doctors. Somehow, in the process of labeling doctors as “primary” and “provider,” these players have over-played their hands, and reduced a noble profession to a dec idedly impersonal business.
It may take a while for these big players to see the error of their ways. Unitl then, I'm reminded of a Casey Stengel tale. After managing the world champion Yankees, Casey managed the lowly Mets. Marv Thornberry was one of his hapless crew. Casey was disgusted with Marv's playing and decided to show him how things were done. Casey took to the field, had a fungo fly hit to him -- and dropped the ball. He turned to Thornberry and shouted, "Marv, you've got this position so fowled up, nobody can play it!" The same may hold true for payers who have placed physicians on the field of play as quasi-employees.
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Future - Viewing the Hospital of the Future through the Lens of Complexity
View your system through the lens of complexity.
Brenda Zimmerman, Curt Lindberg, and Paul Pizek, Edgeware: Insights from Complexity Science for Healthcare Leaders (VHA, Inc, 1998)
Hospitals will no longer be expected to just diagnose disease, prescribe medications, and perform surgeries. Rather hospitals will be part wellness centers, part hospice, part nursing school, part medical group. In short, patients and their families will want integrated features from across the provider spectrum.
Molly Rowe, “The Hospital of the Future,” Healthleaders Magazine, July 11, 2008
This is my 605th blog, roughly 604 more than medical world needs, for there is surely one remains worth savoring.
Nonetheless, on the other hand, the health care system is so complex, with so many niches, gaps, crevices, crevasses, chasms, hills, valleys, tectonic faults, convexities, concavities, choices, options, perplexities, innovations, opportunities, and problems to be solved and explored, that I persist in my quest to explain what is going on, in this case, with the hospital of the future.
In Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), I devoted four chapters to hospital innovations.
• “From Hospitals to Physician-Integrated Hospitals” – In it I posed two big questions for hospitals and doctors: integration or disintegration? I suggest one possible solution: join together as equity partners in a large 25,000 to 50,000 ambulatory square foot facility known as a “Big Box.”
• “Making Rooms for Boomers” – Here I described the hospital building boom of new patient and eco-friendly hospitals designed for aging babyboomers.
• “New Partners for Building and Financing Big MACCs” – Big MACCs are Multispecialty Ambulatory Care Centers build to accommodate and to cater to affluent suburban and exurban denizens in underserved medical regions.
• “From Independent Specialty Practice to Hospital Employment” – Here I dwelt on the rush of primary care doctors and specialists alike to be employed by hospitals, and the innovative possibilities and perverse incentives of this model, which has become known as the “staff model.”
From the experience of writing these chapters, I concluded; when I am re-incarnated, I do not want to be a future hospital CEO. The job will simply be too damn complex for any ordinary mortal.
The future CEO will have to be a contortionist, with a finger to the wind, an ear to the ground, one eye on the horizon, one eye on the rear view mirror, a nose in the air, and all senses focused on simultaneous competition and cooperation with physicians. As the late Peter F. Drucker commented, “One cannot run a hospital with doctors, and one cannot run one without them.”
Then, too, there’s the fundamental managerial impossibility of being all things to all people and doing all things well. As Regina Herzlinger, Harvard Business School Professor and godmother of the consumer-driven movement, has noted, hospitals cannot manage diverse numbers of sophisticated specialized activities and do them all well.
Hospitals tend to view themselves at the centerpiece of community health – as coordinator and last resort of all things related to health and disease and the only facility open 24/7 to receive all comers. This is certainly true when one thinks of the emergency room.
But options to the hospital are continually opening up, in the form of retail clinics, worksite clinics, urgent care centers, ambulatory clinics staffed by specialists, virtual home care supported by monitoring technologies, and specialist-owned hospitals. .
These options are taking their toll on hospitals, which are seeing slowing growth and drops in the number of admissions. The great migration outside the hospital, towards more consumer-friendly settings outside hospitals, is gathering a head of steam.
At the same time, physicians are flocking to hospitals to be employed. This is understandable in this age of low physician morale, economic difficulties in managing physician small businesses, the harassments of managed care, dropping health plan reimbursements, mounting accounts receivable, rising practice costs, not the least of which are onerous malpractice premiums.
But hospital employment of mass numbers of physicians has perverse incentives as well. Hospitals may take 80% of physician production as overhead. Collecting only 20% of what one produces is not a powerful incentive for physician productivity and may result in physicians taking advantages of the fringe benefits of hospital employment – a short working week, more time off, more vacation. Many primary care physicians are turning to ER and hospitalists work, but the expense of these specialists is fast becoming a significant expense burden for hospitals.
Physician employment is not a potent stimulant for reducing overall costs. To maintain growth and produce a profit margin, hospitals often insist employed physicians channel all referred work, particularly high-ticket items such as CT, MRI, and PET scans and costly cancer care to in-house specialists and facilities. Hospital services are invariably more expensive than those offered on the outside.
Still, after all is said and done, hospitals in most cases remain the largest employer in any given town, and hospitals have access to the capital needed to survive in today’s hotly competitive environment. Well-heeled specialists, however, the main strut of hospitals’ profitability, may prefer to remain independent.
As I said in the beginning, being a hospital CEO in today’s complex environment is tough. As laid out in Edgeware, the CEO job requires flexibility with a good-enough vision of what needs to be done, balancing data and risk, dealing with physician diversity and differences, honoring safety and risk, taking multiple actions at the edges, paying rapt attention to gossip and informal physician relationships, and competing and cooperating with doctors at the same tie. It’s job for the hardy and hard-headed, and for someone with a deep knowledge of the physician
Wednesday, August 20, 2008
E-Medicine, virtual medicine - E-Medicine for Routine Ailments: Virtual Vs. Face-to-Face Visits
A compelling reason for Internet medicine is you can treat patients without them being in your physical presence. If you’re paid for the e-visit, that may makes this form of medicine practical. For patients, benefits are convenience, time saved, being spared from parking and travel expenses.
Here, Benjamin Brewer, MD, the WSJ’s Doctor’s Office Forum blogger, discusses e-medicine.
My patient probably would have rather been anywhere else. He and his wife were in my office to discuss his erectile dysfunction for the first time.
He looked uncomfortable. For a guy who doesn't go to the doctor much, a medical office can seem as foreign and intimidating as the dark side of the moon.
His exam was normal, but he needed to quit smoking. Would it have been easier for you to fill out a questionnaire on the Internet and skip the office visit? I asked. "You bet," he replied.
The way I see it, he didn't really need to come in at all. He needed a risk assessment for heart disease, a prescription for medication, counseling and help with stopping smoking. The results would have been the same online or in person.
The average American's health-care experience is fraught with high cost, poor service and uncertain quality. But the prudent practice of medicine online would improve health care on all three counts.
Patients want access to safe, reliable medical care on the Internet, just like banking, shopping or booking a flight. Eighty percent of the public want doctors to use email to communicate with patients, but only 9% of physicians actually do that even occasionally.
I think 20% of my routine office visits could be handled safely and less expensively over the Internet. There is nothing magical about the four office walls that make face-to-face visits superior. Demanding an in-person visit for every little thing is based on tradition and consensus opinion -- not science.
Doctors trot out excuses about why they don't use the Internet as a tool for working with patients. I think doctors' big fear is that the online discussions with patients will eat up time, with little or no extra payment for the service.
A big impediment is that in most states it is illegal to prescribe drugs for a patient based on an online evaluation. That seems strange to me because physicians have been prescribing medicines by telephone for simple things without the safety net the computer provides.
Of course, there have been cases of inappropriate prescribing of narcotic medications in my home state, Illinois, and others. And regulators put the clamps on even legitimate use of Internet medicine without a face-to-face physical exam.
The medical establishment has been reluctant to embrace online medicine. Indeed, medical societies and the Federation of State Medical Boards have taken a very aggressive position against Internet prescribing in the name of patient safety. In their world, only in-person visits are thought to be safe.
Are the boards of medical examiners' policies really protecting patient safety or only mandating face-to-face office visits as economic protection for doctors, I wonder.
If I tried to prescribe ED drugs today based on an Internet questionnaire and email correspondence, the state medical board could take my license away and fine me thousands of dollars for every patient I treated.
I have no desire to be a Viagra prescription mill. I bring up the medicine because ED care over the Internet is probably the most studied of online options.
There are broader applications for Internet treatment beyond ED. And to be absolutely clear, there's no evidence that only face-to-face office visits are safe, effective and high-quality.
Traditionalists in medicine may be afraid to learn how good Internet medicine can be. One of the first substantial studies of Internet medicine was conducted by the University of Utah and published this month in the journal Mayo Clinic Proceedings. The researchers compared traditional office treatment of erectile dysfunction versus Internet practice.
The patients treated online had no face-to-face exam. The traditional doctors had the benefit of a computerized record system but they still lost out to the Internet doctors, who took a more thorough history and provided more counseling with the aide of a standardized Internet-based system.
Internet practice for ED was equal to traditional office practice or safer in all areas studied.
As a small-town doctor who still makes house calls, the prospect of an Internet practice is quite a departure from business as usual. As the Internet-savvy population ages and the number of primary care doctors dwindles, the demand for safe online medicine will grow.
Until the regulators come around to the advantages of Internet medicine, patients will continue to miss work over minor ailments and I'll keep seeing them at the office.
References
1. Benjamin Brewer MD, Internet Visits With Doctors Can Beat Office Appointments, August 20, 2008.
2. Mark Munger, et al, Safety of Prescribing PDE-Inhibitors via e-Medicine vs Traditional Medicine, Mayo Clin Pr0, August, 2008.
Here, Benjamin Brewer, MD, the WSJ’s Doctor’s Office Forum blogger, discusses e-medicine.
My patient probably would have rather been anywhere else. He and his wife were in my office to discuss his erectile dysfunction for the first time.
He looked uncomfortable. For a guy who doesn't go to the doctor much, a medical office can seem as foreign and intimidating as the dark side of the moon.
His exam was normal, but he needed to quit smoking. Would it have been easier for you to fill out a questionnaire on the Internet and skip the office visit? I asked. "You bet," he replied.
The way I see it, he didn't really need to come in at all. He needed a risk assessment for heart disease, a prescription for medication, counseling and help with stopping smoking. The results would have been the same online or in person.
The average American's health-care experience is fraught with high cost, poor service and uncertain quality. But the prudent practice of medicine online would improve health care on all three counts.
Patients want access to safe, reliable medical care on the Internet, just like banking, shopping or booking a flight. Eighty percent of the public want doctors to use email to communicate with patients, but only 9% of physicians actually do that even occasionally.
I think 20% of my routine office visits could be handled safely and less expensively over the Internet. There is nothing magical about the four office walls that make face-to-face visits superior. Demanding an in-person visit for every little thing is based on tradition and consensus opinion -- not science.
Doctors trot out excuses about why they don't use the Internet as a tool for working with patients. I think doctors' big fear is that the online discussions with patients will eat up time, with little or no extra payment for the service.
A big impediment is that in most states it is illegal to prescribe drugs for a patient based on an online evaluation. That seems strange to me because physicians have been prescribing medicines by telephone for simple things without the safety net the computer provides.
Of course, there have been cases of inappropriate prescribing of narcotic medications in my home state, Illinois, and others. And regulators put the clamps on even legitimate use of Internet medicine without a face-to-face physical exam.
The medical establishment has been reluctant to embrace online medicine. Indeed, medical societies and the Federation of State Medical Boards have taken a very aggressive position against Internet prescribing in the name of patient safety. In their world, only in-person visits are thought to be safe.
Are the boards of medical examiners' policies really protecting patient safety or only mandating face-to-face office visits as economic protection for doctors, I wonder.
If I tried to prescribe ED drugs today based on an Internet questionnaire and email correspondence, the state medical board could take my license away and fine me thousands of dollars for every patient I treated.
I have no desire to be a Viagra prescription mill. I bring up the medicine because ED care over the Internet is probably the most studied of online options.
There are broader applications for Internet treatment beyond ED. And to be absolutely clear, there's no evidence that only face-to-face office visits are safe, effective and high-quality.
Traditionalists in medicine may be afraid to learn how good Internet medicine can be. One of the first substantial studies of Internet medicine was conducted by the University of Utah and published this month in the journal Mayo Clinic Proceedings. The researchers compared traditional office treatment of erectile dysfunction versus Internet practice.
The patients treated online had no face-to-face exam. The traditional doctors had the benefit of a computerized record system but they still lost out to the Internet doctors, who took a more thorough history and provided more counseling with the aide of a standardized Internet-based system.
Internet practice for ED was equal to traditional office practice or safer in all areas studied.
As a small-town doctor who still makes house calls, the prospect of an Internet practice is quite a departure from business as usual. As the Internet-savvy population ages and the number of primary care doctors dwindles, the demand for safe online medicine will grow.
Until the regulators come around to the advantages of Internet medicine, patients will continue to miss work over minor ailments and I'll keep seeing them at the office.
References
1. Benjamin Brewer MD, Internet Visits With Doctors Can Beat Office Appointments, August 20, 2008.
2. Mark Munger, et al, Safety of Prescribing PDE-Inhibitors via e-Medicine vs Traditional Medicine, Mayo Clin Pr0, August, 2008.
Hospitals and Doctors - Physician-Led Hospital Turnabouts
An August 2 Boston Globe article “Cape Cod Hospital CEO Maps Turnaround.” opens:
Dr. Richard Saluzzo, the new chief executive of Cape Cod Health Care in Hyannis, says he plans to rebuild his health system’s relationship with doctors and create a “physician-led organization” as he seeks to turn around the cash strapped organization
Saluuzon says, “the medical staff leadership group is going to run this hospital with us. They will be actively involved in all decisions. Now there is suspicion and distrust between the doctors and the hospital. We need down those barriers.
I pray Dr. Saluzzo succeeds. Cape Cod needs its hospital system, not only for its care but as the Cape’s largest employer. Cape Cod Health Care employs 4000. In the year ending May 31, the system lost $24 million, partly because its doctors referred high-tech high-ticket procedures, like MRI and CT scans, to outside facilities. Another problem, says Salluzzo, is that system employs 33 hospitalists. For a system of 313 beds, this may be an excessive number. Until recently hiring hospitalists was considered the rage for most hospitals.
I find this story intriguing for personal and global reasons. I had a home in Falmouth for 20 years and was fascinated by that vacation-bound peninsula’s quirky economic climate. More broadly, it brings home the message that hospitals had better bring doctors into the decision-making process if they are to succeed. Doctors are hospitals’ main customers. Without doctors, hospitals would be empty shells with mediocre food.
Hospital financial failures are not rare, with Medicare revenues flattening, health plan reimbursement tightening, doctors setting up competitive facilities, and consumers gravitating to ambulatory settings. Turning failing hospital around requires;
• rallying doctor leaders around a common cause,
• attacking problems on multiple fronts (cutting staff, renegotiating contracts, collecting money owed, coding properly, restructuring debt, improving revenue cycles, enhancing productivity, bolstering morale, cutting supply expenses, building on strengths, and seizing key opportunities)
Turnarounds often succeed within one to two years:
• Maricopa Medical Center from $12 million debt to $25 million profit in a year,
• New England Medical Center from a $4.7 million loss to $400,000 surplus in year,
• Crouse Hospital in Syracuse from $91 million to in the black in 2 years,
• Detroit Medical Center from $60 million in losses to break even in two years.
One lesson is crystal clear. effective CEO and physician leaderships are absolutely essential If the CEO happens to be a physicians,that process may be expedited. In our book, Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control, and Cash (PSR Publications, 2006), James Hawkins, a former hospital administrator, and I observed better physician relationships, even formal partnerships, will be required for future hospital viability and stability.
Dr. Richard Saluzzo, the new chief executive of Cape Cod Health Care in Hyannis, says he plans to rebuild his health system’s relationship with doctors and create a “physician-led organization” as he seeks to turn around the cash strapped organization
Saluuzon says, “the medical staff leadership group is going to run this hospital with us. They will be actively involved in all decisions. Now there is suspicion and distrust between the doctors and the hospital. We need down those barriers.
I pray Dr. Saluzzo succeeds. Cape Cod needs its hospital system, not only for its care but as the Cape’s largest employer. Cape Cod Health Care employs 4000. In the year ending May 31, the system lost $24 million, partly because its doctors referred high-tech high-ticket procedures, like MRI and CT scans, to outside facilities. Another problem, says Salluzzo, is that system employs 33 hospitalists. For a system of 313 beds, this may be an excessive number. Until recently hiring hospitalists was considered the rage for most hospitals.
I find this story intriguing for personal and global reasons. I had a home in Falmouth for 20 years and was fascinated by that vacation-bound peninsula’s quirky economic climate. More broadly, it brings home the message that hospitals had better bring doctors into the decision-making process if they are to succeed. Doctors are hospitals’ main customers. Without doctors, hospitals would be empty shells with mediocre food.
Hospital financial failures are not rare, with Medicare revenues flattening, health plan reimbursement tightening, doctors setting up competitive facilities, and consumers gravitating to ambulatory settings. Turning failing hospital around requires;
• rallying doctor leaders around a common cause,
• attacking problems on multiple fronts (cutting staff, renegotiating contracts, collecting money owed, coding properly, restructuring debt, improving revenue cycles, enhancing productivity, bolstering morale, cutting supply expenses, building on strengths, and seizing key opportunities)
Turnarounds often succeed within one to two years:
• Maricopa Medical Center from $12 million debt to $25 million profit in a year,
• New England Medical Center from a $4.7 million loss to $400,000 surplus in year,
• Crouse Hospital in Syracuse from $91 million to in the black in 2 years,
• Detroit Medical Center from $60 million in losses to break even in two years.
One lesson is crystal clear. effective CEO and physician leaderships are absolutely essential If the CEO happens to be a physicians,that process may be expedited. In our book, Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control, and Cash (PSR Publications, 2006), James Hawkins, a former hospital administrator, and I observed better physician relationships, even formal partnerships, will be required for future hospital viability and stability.
Tuesday, August 19, 2008
Primry care - Transitioning from a Specialty-Dominated to a Primary-Driven Health System
In an ideal world, how would America transition from the present specialist dominated to a primary-driven system?
Logic of a Primary-Driven System
Among primary care advocates, the logic goes like this.
Medicine is a science. Science relies on data. Data indicates funneling all patients though a primary care network with doctors armed with EMRs containing best practice data costs less and improves care. Data separates good doctors, those who cost less and have good results, from bad doctors who overcharge and have less good results.
Pay Only for Filtered Care
Consequently, to improve care, buyers should pay only for data-justified care filtered through primary care doctors. These doctors, using aggregated specialist data, will have sufficient knowledge to refer only to good specialists = those who deliver good results at low costs. Consumers who choose not to go through primary care physicians, and who instead go directly to specialists, will pay out-of-pocket.
Caveats
This is imminently logical. The trouble is: it may not work. Why not? Medicine is an art, and many visits have little to do with science. Care involves handling a mixed bag of humanity = the seriously ill, the worried well, those who seek to prevent disease, those who simply want to consult with their doctor.
The American culture rests on individualism and freedom of choice. Forcing patients through primary care filters creates a level of bureaucracy. Consumers and specialists will object. A severe shortage of primary care physicians currently exists, and being forced to see them may require month-long waits.
Besides, what defines primary care physicians? Many gynecologists and internal medicine subspecialties serve as family physicians. Furthermore, American consumers think they are smart enough to go to obvious specialist for obvious problems. Americans expect direct and quick access to technologies, now in the hands of specialists. The political obstacles are formidable – specialty societies, high tech hospitals, and even consumer organizations. Many of these obstacles are psychological and have little to do with science and data.
Emerging Power of Primary Care
In my last blog, I described the emerging primary care paradigm. I noted its power to change the health system by placing patients and primary care physicians at the center of care...
The new paradigm differs from the managed care “gatekeeper model” because it rewards primary doctors for same-day appointments, telephone and email consultations, coordinating care, and giving doctors “ownership” of the process of selecting the proper specialists through e- knowledge of specialists’ “value”, i.e. their performance, price, and outcomes. Just paying primary care doctors for telephone consultations could make a tremendous difference, since these doctors may spend at much ½ to 1/3 of their working day on the phone.
The “medical home” and referral “ownership” concepts are based on computer information platforms that aggregate data on specialty performance and cost data. Carrying out these concepts and changing the current specialty paradigm will not be easy. Understanding and transforming the specialty paradigm is not a trivial matter since specialists comprise 2/3s of American physicians and dominate medicine.
The Specialty Paradigm
What is this paradigm? It’s a logical, predictable, entrenched, and taken-for-granted approach to health care. It’s performed by highly trained specialists who are board-certified experts in their fields. Specialists feel they should have authority and freedom to order procedures and tests they deem appropriate. However, buyers of care may think specialists abuse these privileges by doing unnecessary work for personal gain.
Americans Cater to Specialists
Americans may stand in awe of specialists who crack sternums, replace joints, open skulls, enter GI tracts, examine orifices, look inside bodies, and diagnose, treat, and cure rare and difficult disorders. .Specialists is admired as “doers” rather than strictly thinkers. Americans like those who do and are willing to pay for what they do...Doing is concrete and billable; thinking is abstract and hard to itemize.
Vertical vs. Lateral Thinkers
The specialist paradigm is a prime example of “vertical thinking,” a straight-forward, linear, and scientific approach to solving problems. Vertical thinking differs from “lateral thinking,” solving problems by unconventional, innovative, and creative means.
Edward de Bono, MD, founder of Thinking Institute in Malta and author of more than 60 books, invented the concept of lateral or creative thinking. In health care, de Bono once explained the differences in vertical and lateral thinking in this way.
Vertical thinkers dig deeper and deeper holes across the health care landscape. At the bottom of each hole, you will find a world class expert. The only problem is the various vertical holes don’t connect. One specialist may not know what the other specialist is doing and may have no means of communicating with him/her colleagues or hospitals.
The lateral thinker, on other hand, roams the countryside looking for connections, seeking ways to put things together into an integrated whole, searching for a system blending relationships and eliminating care gaps, and hunting for self-organizing information platforms and disruptive innovations that lower costs and that work outside traditional specialty silos.
There are, of course, examples on integrated systems – Kaiser, Mayo, the VA, the Cleveland Clinic, and academic institutions. Most hire salaried physicians with a common institutional mission and with primary care physicians and specialists working in tandem.
These systems are admirable, but most independent practitioners don’t have the resources or infrastructure to implement what integrated systems do. These institutions are the exception rather the rule for U.S. health care. They care for perhaps 10% to 12% of patients. Consequently, many patients must wend their way through the maze, sometimes falling through the cracks, sometimes seeing care duplicated, and sometimes undergoing needless procedures.
Individualism
The typical Medicare patient with chronic disease sees six different specialists, some of whom are unaware of the other. Individualism is often the modus operandi among doctors and patients. Many patients believe they have enough sense to make their own decisions and choose their own specialists. Besides, they may enjoy the freedom of picking dermatologists for skin problems, ophthalmologists for eye disorders, bar iatric surgeons for obesity, orthopedists for joint conditions, and so forth, commonly on the basis of word of mouth from relatives, friends, or neighbors.
Hospitals Promote Specialists
Hospitals recruit and promote high tech specialists, who contribute 80% to 90% of their bottom lines. Hospital marketing departments unabashedly promote expertise of doctors armed with the latest robotic surgical device, computer imaging device, or heart disease detection equipment. These activities are typical of hospital high tech marketing wars, designed to show who is on the cutting edge.
Reimbursement Favors Specialists
In the meantime, some primary care doctors may suffer economically because specialists essentially control the coding rates through the AMA’s RBVS Update Committee (RUC). RUC rewards specialists more handsomely than primary care physicians (see www.medinnovationblog.blogspot.com, “The RUC (“RBVS Update Committee ) Ruckus,” December 11, 2007, and are reluctant to give up any of their revenues to primary care physicians in a revenue neutral environment.
Quality’s Multiple Dimensions
Meanwhile arguments rage on what constitutes “quality,” how to prove it,” and how to improve it. Quality often resides in the eye of the beholder. Some say it rests on data, others on convenience and satisfaction. In reality, quality is combination of patient satisfaction and anxiety, physician personality, convenient and timely access, and performance and outcome measures. These factors aren’t easily be teased from one another.
Sensible business buyers tend to define quality as physicians or systems that satisfy employees while following “best practices.” The Patient-Centered Primary Care Collaborative believes the greatest satisfaction, lowest costs, and best care, collectively constitute “quality,” and its achievement lies in comprehensive primary care. Specialty societies may think otherwise, i.e., in procedures done well by “best” or “top” doctors, whether performed independently, in isolation, or as part of a larger institutional system. .
Consumers tend to equate quality with being seen promptly and efficiently by primary care physicians close to home and being seen, operated upon, or having procedures by top-grade specialists in the immediate region. Reputation is paramount in consumers’ eyes. This is one reason hospital marketing is so effective. Consumers don’t pay much attention to Internet rating systems. Payers may equate quality with patient satisfaction; others with price, outcome, and adherence to best-practice metrics.
To paraphrase President Bill Clinton, quality depends on what “is” is. Quality, like sex, is a slippery subject. Quality depends partly on the participants’ satisfaction, partly on personal desires, partly on metrics, and partly on the aftermath.
Conclusion: Changing the specialist paradigm may be more difficult than transforming the primary care paradigm. The real world is a messy place. Doctors don’t always fall neatly into categories. Some primary care doctors specialize. Some specialists do primary care. Some thinkers do. Some doers think. Most do what needs to be done in spite of their category. Those who think otherwise may be suffering from hardening of the categories. Nevertheless, because of relentlessly rising buyer costs, ever growing consumer dissatisfaction, and uneven quality, the primary care paradigm has reached a tipping point, and ultimately, specialists may follow
Logic of a Primary-Driven System
Among primary care advocates, the logic goes like this.
Medicine is a science. Science relies on data. Data indicates funneling all patients though a primary care network with doctors armed with EMRs containing best practice data costs less and improves care. Data separates good doctors, those who cost less and have good results, from bad doctors who overcharge and have less good results.
Pay Only for Filtered Care
Consequently, to improve care, buyers should pay only for data-justified care filtered through primary care doctors. These doctors, using aggregated specialist data, will have sufficient knowledge to refer only to good specialists = those who deliver good results at low costs. Consumers who choose not to go through primary care physicians, and who instead go directly to specialists, will pay out-of-pocket.
Caveats
This is imminently logical. The trouble is: it may not work. Why not? Medicine is an art, and many visits have little to do with science. Care involves handling a mixed bag of humanity = the seriously ill, the worried well, those who seek to prevent disease, those who simply want to consult with their doctor.
The American culture rests on individualism and freedom of choice. Forcing patients through primary care filters creates a level of bureaucracy. Consumers and specialists will object. A severe shortage of primary care physicians currently exists, and being forced to see them may require month-long waits.
Besides, what defines primary care physicians? Many gynecologists and internal medicine subspecialties serve as family physicians. Furthermore, American consumers think they are smart enough to go to obvious specialist for obvious problems. Americans expect direct and quick access to technologies, now in the hands of specialists. The political obstacles are formidable – specialty societies, high tech hospitals, and even consumer organizations. Many of these obstacles are psychological and have little to do with science and data.
Emerging Power of Primary Care
In my last blog, I described the emerging primary care paradigm. I noted its power to change the health system by placing patients and primary care physicians at the center of care...
The new paradigm differs from the managed care “gatekeeper model” because it rewards primary doctors for same-day appointments, telephone and email consultations, coordinating care, and giving doctors “ownership” of the process of selecting the proper specialists through e- knowledge of specialists’ “value”, i.e. their performance, price, and outcomes. Just paying primary care doctors for telephone consultations could make a tremendous difference, since these doctors may spend at much ½ to 1/3 of their working day on the phone.
The “medical home” and referral “ownership” concepts are based on computer information platforms that aggregate data on specialty performance and cost data. Carrying out these concepts and changing the current specialty paradigm will not be easy. Understanding and transforming the specialty paradigm is not a trivial matter since specialists comprise 2/3s of American physicians and dominate medicine.
The Specialty Paradigm
What is this paradigm? It’s a logical, predictable, entrenched, and taken-for-granted approach to health care. It’s performed by highly trained specialists who are board-certified experts in their fields. Specialists feel they should have authority and freedom to order procedures and tests they deem appropriate. However, buyers of care may think specialists abuse these privileges by doing unnecessary work for personal gain.
Americans Cater to Specialists
Americans may stand in awe of specialists who crack sternums, replace joints, open skulls, enter GI tracts, examine orifices, look inside bodies, and diagnose, treat, and cure rare and difficult disorders. .Specialists is admired as “doers” rather than strictly thinkers. Americans like those who do and are willing to pay for what they do...Doing is concrete and billable; thinking is abstract and hard to itemize.
Vertical vs. Lateral Thinkers
The specialist paradigm is a prime example of “vertical thinking,” a straight-forward, linear, and scientific approach to solving problems. Vertical thinking differs from “lateral thinking,” solving problems by unconventional, innovative, and creative means.
Edward de Bono, MD, founder of Thinking Institute in Malta and author of more than 60 books, invented the concept of lateral or creative thinking. In health care, de Bono once explained the differences in vertical and lateral thinking in this way.
Vertical thinkers dig deeper and deeper holes across the health care landscape. At the bottom of each hole, you will find a world class expert. The only problem is the various vertical holes don’t connect. One specialist may not know what the other specialist is doing and may have no means of communicating with him/her colleagues or hospitals.
The lateral thinker, on other hand, roams the countryside looking for connections, seeking ways to put things together into an integrated whole, searching for a system blending relationships and eliminating care gaps, and hunting for self-organizing information platforms and disruptive innovations that lower costs and that work outside traditional specialty silos.
There are, of course, examples on integrated systems – Kaiser, Mayo, the VA, the Cleveland Clinic, and academic institutions. Most hire salaried physicians with a common institutional mission and with primary care physicians and specialists working in tandem.
These systems are admirable, but most independent practitioners don’t have the resources or infrastructure to implement what integrated systems do. These institutions are the exception rather the rule for U.S. health care. They care for perhaps 10% to 12% of patients. Consequently, many patients must wend their way through the maze, sometimes falling through the cracks, sometimes seeing care duplicated, and sometimes undergoing needless procedures.
Individualism
The typical Medicare patient with chronic disease sees six different specialists, some of whom are unaware of the other. Individualism is often the modus operandi among doctors and patients. Many patients believe they have enough sense to make their own decisions and choose their own specialists. Besides, they may enjoy the freedom of picking dermatologists for skin problems, ophthalmologists for eye disorders, bar iatric surgeons for obesity, orthopedists for joint conditions, and so forth, commonly on the basis of word of mouth from relatives, friends, or neighbors.
Hospitals Promote Specialists
Hospitals recruit and promote high tech specialists, who contribute 80% to 90% of their bottom lines. Hospital marketing departments unabashedly promote expertise of doctors armed with the latest robotic surgical device, computer imaging device, or heart disease detection equipment. These activities are typical of hospital high tech marketing wars, designed to show who is on the cutting edge.
Reimbursement Favors Specialists
In the meantime, some primary care doctors may suffer economically because specialists essentially control the coding rates through the AMA’s RBVS Update Committee (RUC). RUC rewards specialists more handsomely than primary care physicians (see www.medinnovationblog.blogspot.com, “The RUC (“RBVS Update Committee ) Ruckus,” December 11, 2007, and are reluctant to give up any of their revenues to primary care physicians in a revenue neutral environment.
Quality’s Multiple Dimensions
Meanwhile arguments rage on what constitutes “quality,” how to prove it,” and how to improve it. Quality often resides in the eye of the beholder. Some say it rests on data, others on convenience and satisfaction. In reality, quality is combination of patient satisfaction and anxiety, physician personality, convenient and timely access, and performance and outcome measures. These factors aren’t easily be teased from one another.
Sensible business buyers tend to define quality as physicians or systems that satisfy employees while following “best practices.” The Patient-Centered Primary Care Collaborative believes the greatest satisfaction, lowest costs, and best care, collectively constitute “quality,” and its achievement lies in comprehensive primary care. Specialty societies may think otherwise, i.e., in procedures done well by “best” or “top” doctors, whether performed independently, in isolation, or as part of a larger institutional system. .
Consumers tend to equate quality with being seen promptly and efficiently by primary care physicians close to home and being seen, operated upon, or having procedures by top-grade specialists in the immediate region. Reputation is paramount in consumers’ eyes. This is one reason hospital marketing is so effective. Consumers don’t pay much attention to Internet rating systems. Payers may equate quality with patient satisfaction; others with price, outcome, and adherence to best-practice metrics.
To paraphrase President Bill Clinton, quality depends on what “is” is. Quality, like sex, is a slippery subject. Quality depends partly on the participants’ satisfaction, partly on personal desires, partly on metrics, and partly on the aftermath.
Conclusion: Changing the specialist paradigm may be more difficult than transforming the primary care paradigm. The real world is a messy place. Doctors don’t always fall neatly into categories. Some primary care doctors specialize. Some specialists do primary care. Some thinkers do. Some doers think. Most do what needs to be done in spite of their category. Those who think otherwise may be suffering from hardening of the categories. Nevertheless, because of relentlessly rising buyer costs, ever growing consumer dissatisfaction, and uneven quality, the primary care paradigm has reached a tipping point, and ultimately, specialists may follow
Saturday, August 16, 2008
Primary care, medical home - Profound Primary Care Paradigm Shift Underway
This is my 600th blog. This fact may indicate: a) I have a bad case of verborrhea, b) I have something to say. I pray it’s the latter. In any case, this blog may be one of my more important and influential ones. This self-righteous assessment assumes what I say will be correct and will come to pass.
Profound Changes in Attitudes
Something profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place..
Signs of Paradigm Shift
Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from failing through the cracks. We must stop wasting time and resources for patients and the system as a whole.
The problem of the U.S. system isn’t quality. It’s timely access to primary doctors who oversee care. And it’s overuse of specialty services. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.
What’s Driving the Paradigm Shift
• Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Technology and Strategic Initiatives, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.
• A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.
• The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real...
• New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 real clinics, 500 worksite clinics, and roughly 3000 urgent care facilities.
• The physician empowerment movement is growing. The Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo.com, a physician social networking site, has 75.000 members and will soon issue an “Open Letter to the American public signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.
Conclusion: A new primary care paradigm is upon and will fundamentally change how the U.S. delivers care.
Profound Changes in Attitudes
Something profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place..
Signs of Paradigm Shift
Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from failing through the cracks. We must stop wasting time and resources for patients and the system as a whole.
The problem of the U.S. system isn’t quality. It’s timely access to primary doctors who oversee care. And it’s overuse of specialty services. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.
What’s Driving the Paradigm Shift
• Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Technology and Strategic Initiatives, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.
• A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.
• The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real...
• New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 real clinics, 500 worksite clinics, and roughly 3000 urgent care facilities.
• The physician empowerment movement is growing. The Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo.com, a physician social networking site, has 75.000 members and will soon issue an “Open Letter to the American public signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.
Conclusion: A new primary care paradigm is upon and will fundamentally change how the U.S. delivers care.
Profound Primary Care Paradigm Shift Underway
This is my 600th bog. This fact may indicate: a) I have a bad case of verborrhea, b) I have something to say. I pray it’s the latter. In any case, this blog may be one of my more important and influential ones. This self-righteous assessment assumes what I say will be correct and will come to pass.
Profound Changes in Attitudes
Something profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place..
Signs of Paradigm Shift
Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from failing through the cracks. We must stop wasting time and resources for patients and the system as a whole.
The problem of the U.S. system isn’t quality. It’s timely access to primary doctors who oversee care. And it’s overuse of specialty services. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.
What’s Driving the Paradigm Shift
• Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Technology and Strategic Initiatives, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.
• A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.
• The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real...
• New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 real clinics, 500 worksite clinics, and roughly 3000 urgent care facilities.
• The physician empowerment movement is growing. The Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo.com, a physician social networking site, has 75.000 members and will soon issue an “Open Letter to the American public signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.
Conclusion: A new primary care paradigm is upon and will fundamentally change how the U.S. delivers care.
Profound Changes in Attitudes
Something profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place..
Signs of Paradigm Shift
Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from failing through the cracks. We must stop wasting time and resources for patients and the system as a whole.
The problem of the U.S. system isn’t quality. It’s timely access to primary doctors who oversee care. And it’s overuse of specialty services. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.
What’s Driving the Paradigm Shift
• Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Technology and Strategic Initiatives, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.
• A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.
• The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real...
• New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 real clinics, 500 worksite clinics, and roughly 3000 urgent care facilities.
• The physician empowerment movement is growing. The Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo.com, a physician social networking site, has 75.000 members and will soon issue an “Open Letter to the American public signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.
Conclusion: A new primary care paradigm is upon and will fundamentally change how the U.S. delivers care.
Friday, August 15, 2008
Remote monitoring, telemedicine - Saving Money and Saving Lives Through Home Monitoring Controlled by Patients Themselves
The Wall Street Journal health blog (www.wsj.com/health) is one of my favorites. Jacob Goldstein, its chief blogger, posted this blog on August 14.
Medicare Could Save Billions By Cutting Re-Hospitalization
Posted by Jacob Goldstein
One possible sweet spot for trimming the growing cost of Medicare: repeat hospital visits.
The percentage of patients who return to the hospital with in 30 days of being discharged could be cut dramatically, says an op-ed in this morning’s Boston Globe. A MedPAC study found that potentially preventable readmissions cost Medicare some $12 billion in 2005.
Perhaps most important is better communication when patients are discharged and better monitoring of patients after they leave the hospital. One medical center lowered readmission rates for cardiac patients by 78% when nurses called the patients at home to check on key signs such as weight, swelling, and shortness of breath.
Medicare should bundle funding for this kind of follow-up monitoring in its payment for the patient’s initial hospital stay, and “claw back” the initial payment for any patient who is re-admitted to any hospital within 30 days, the authors suggest.
Jacob did not mention a couple of things:
1) cutting re-admissions saves hospitals a bundle of money since hospitals are paid a fixed amount for a given diagnosis, and patients readmitted within 30 days fall under that fixed amount and frequently exceed it;
2) a number of firms have already developed software and home monitoring systems that dramatically cut readmissions.
I am most familiar with American Telecare, a telecommunications firm in Eden Prairie, Minnesota. I have a chapter on the firm in my book Innovation-Driven Health Care. The chapter is titled “From High Tech to High Tech/High Touch.” The chapter features a case study co-written by Randall Moore, CEO of American Telecare, and Erin Denholm, MSN, CEO of Centura Health.
Using an audio-visual bedside device allowing home-bound patients to talk directly, to examine, and to be viewed by doctors and nurses, American Telecare was able to cut re-admissions to near zero. The most dramatic results occurred in patients with congestive heart failure.
What impressed me what that patients controlled the virtual encounter and learned quickly how to spot complications and manage their own disease. Patients, even frail, home-bound patients with chronic disease are quick learners when qiven the opportunity and the tools.
Medicare Could Save Billions By Cutting Re-Hospitalization
Posted by Jacob Goldstein
One possible sweet spot for trimming the growing cost of Medicare: repeat hospital visits.
The percentage of patients who return to the hospital with in 30 days of being discharged could be cut dramatically, says an op-ed in this morning’s Boston Globe. A MedPAC study found that potentially preventable readmissions cost Medicare some $12 billion in 2005.
Perhaps most important is better communication when patients are discharged and better monitoring of patients after they leave the hospital. One medical center lowered readmission rates for cardiac patients by 78% when nurses called the patients at home to check on key signs such as weight, swelling, and shortness of breath.
Medicare should bundle funding for this kind of follow-up monitoring in its payment for the patient’s initial hospital stay, and “claw back” the initial payment for any patient who is re-admitted to any hospital within 30 days, the authors suggest.
Jacob did not mention a couple of things:
1) cutting re-admissions saves hospitals a bundle of money since hospitals are paid a fixed amount for a given diagnosis, and patients readmitted within 30 days fall under that fixed amount and frequently exceed it;
2) a number of firms have already developed software and home monitoring systems that dramatically cut readmissions.
I am most familiar with American Telecare, a telecommunications firm in Eden Prairie, Minnesota. I have a chapter on the firm in my book Innovation-Driven Health Care. The chapter is titled “From High Tech to High Tech/High Touch.” The chapter features a case study co-written by Randall Moore, CEO of American Telecare, and Erin Denholm, MSN, CEO of Centura Health.
Using an audio-visual bedside device allowing home-bound patients to talk directly, to examine, and to be viewed by doctors and nurses, American Telecare was able to cut re-admissions to near zero. The most dramatic results occurred in patients with congestive heart failure.
What impressed me what that patients controlled the virtual encounter and learned quickly how to spot complications and manage their own disease. Patients, even frail, home-bound patients with chronic disease are quick learners when qiven the opportunity and the tools.
Thursday, August 14, 2008
Clinical innovation, innovation centers - Fixing Health Care from the Inside Out
In my last blog, August 13, “Physicians Moving Towards the Internet; Slowly but Not So Surely,” I expressed the opinion that health care will not be fixed from the “outside” – by IT experts or policy or management wonks outside of medicine who think their software solutions hold the key to improving care and will overcome unwilling, un-enabled, and un-incented doctors who resist change for their own personal gain rather than for the good of the system.
The counter-view is that physicians leaders and innovators may be able to fix the system from the “inside out” by creating solutions within the physician community that are workable, flexible, practical, and acceptable to doctors. One such physician leader is Lyle Berkowitz, MD, a practicing internist and the chief medical information officer for the 120 person Northwestern Memorial medical group in Chicago. Berkowitz, who has an educational background in biomedical engineering, head the recently formed nonprofit Szollosi Healthcare Innovation Program at Northwestern Memorial. He recently returned from a tour of leading health care innovation centers across America.
My connection with Berkowitz stems from an interview I conducted with him. The interview appears in the August 13 issue Health & Human Networks Most Wired Magazine (Richard L. Reece, MD, “Fixing Health Care from the Inside, Part One, www.hhnmostwired.com). Here are a few things that Berkowitz had to say.
• Health care must be re-engineered from the inside with doctors taking the lead to create a more efficient and effective system.
• We have plenty of doctors; we are just not deploying them well in ways to produce better and less costly care.
• Primary care doctors ought to be leaders and managers of medical teams, e.g., as proposed in medical home models.
• Primary care practitioners ought to delegate routine care – colds, urinary tract infections, and stable diabetes – to a variety of physician extenders using protocol, evidence-based, protocols.
• Physicians ought to restrict their patient one-on-one time to patients with serious or complicated diseases.
• The reimbursement system ought to changed to reward physicians who lead medical teams that handle large patient populations, who care of patients well, who show demonstrable outcomes; payments should not be based on how often they see patients.
• His model requires an EMR system that supports protocol-based care, population management, and delivery of virtual care via phone or the Web. Not every patient needs to be seen.
• Physicians ought to apply the same level of ingenuity and innovative thinking to creating new business models and transforming care processes that have to developing new devices and new drugs.
• Physicians ought to be open to new ideas, to be inspired by physician innovators with new thinking, to sharing those ideas with colleagues, and to participating in innovation centers springing up around the country.
Commentary on Part Two of the Berkowitz interview will appear in a future blog
The counter-view is that physicians leaders and innovators may be able to fix the system from the “inside out” by creating solutions within the physician community that are workable, flexible, practical, and acceptable to doctors. One such physician leader is Lyle Berkowitz, MD, a practicing internist and the chief medical information officer for the 120 person Northwestern Memorial medical group in Chicago. Berkowitz, who has an educational background in biomedical engineering, head the recently formed nonprofit Szollosi Healthcare Innovation Program at Northwestern Memorial. He recently returned from a tour of leading health care innovation centers across America.
My connection with Berkowitz stems from an interview I conducted with him. The interview appears in the August 13 issue Health & Human Networks Most Wired Magazine (Richard L. Reece, MD, “Fixing Health Care from the Inside, Part One, www.hhnmostwired.com). Here are a few things that Berkowitz had to say.
• Health care must be re-engineered from the inside with doctors taking the lead to create a more efficient and effective system.
• We have plenty of doctors; we are just not deploying them well in ways to produce better and less costly care.
• Primary care doctors ought to be leaders and managers of medical teams, e.g., as proposed in medical home models.
• Primary care practitioners ought to delegate routine care – colds, urinary tract infections, and stable diabetes – to a variety of physician extenders using protocol, evidence-based, protocols.
• Physicians ought to restrict their patient one-on-one time to patients with serious or complicated diseases.
• The reimbursement system ought to changed to reward physicians who lead medical teams that handle large patient populations, who care of patients well, who show demonstrable outcomes; payments should not be based on how often they see patients.
• His model requires an EMR system that supports protocol-based care, population management, and delivery of virtual care via phone or the Web. Not every patient needs to be seen.
• Physicians ought to apply the same level of ingenuity and innovative thinking to creating new business models and transforming care processes that have to developing new devices and new drugs.
• Physicians ought to be open to new ideas, to be inspired by physician innovators with new thinking, to sharing those ideas with colleagues, and to participating in innovation centers springing up around the country.
Commentary on Part Two of the Berkowitz interview will appear in a future blog
Wednesday, August 13, 2008
E-medicine, health 2.0 - Physicians Moving Towards the Internet:
Technology is a queer thing. It brings you great gifts on one hand, and it stabs you in the back with the other.
C.P. Snow, New York Times, 1971
To know and not to do is not to do; Knowledge does become power until it is used.
Harvey McKay, Swim with the Sharks without Being Eaten Alive
Big Brother is watching you.
George Orwell, 1984
To hear Health 2.0 and Health 3.0 seers tell it, Internet medicine is already upon us and will revolutionize medicine.
But for physicians, Internet medicine has yet to prove itself. The Internet may bring great gifts, but it brings trouble too and often does not translate into human terms or address practical practice problems. In its current state, most information technology (IT) does not bring useful clinical knowledge, and it is used more for clinical surveillance than advancing care. Physicians do not use much of this new knowledge, and it remains fallow information.
This, in essence, is what I told a reporter who interviewed me for The Record Magazine, an online publication for IT health care professionals.
Here are a few of my thoughts on why Internet Medicine adoption is so slow.
1) Elephant in the Room
Before resigning as President Bush’s health information czar, David Brailer, M.D., said small physician practices were the elephant in the room – the main obstacle blocking progress toward a national interoperable functioning system. He was right. Small practices do not have money, time, and human resources to install and adopt EMRs that disrupt practice flow, show return on investment, or tangible incentives for using. These are some of the reasons why only 4% of doctors have fully functioning EMRs and only 14% have basic EMRs. Until IT gurus walk in the doctors’ moccasins, they will be like blind men feeling the elephants.
2) Hammers and Nails
Two thirds of U.S. doctors are specialists. Medical specialists have a hammer – a set of skills – to hit a nail – to perform procedures for patients who need those skills. IT specialists also have a hummer – computer software – and they also have a nail to hit – building software to minimize: unneeded procedures. IT specialists sometime forget. The suffer from funnel vision and forget that every specialty has different EMR needs. Conflicts are inevitable, and medical specialists will be skeptical and even hostile towards IT specialists.
3) Giant Invoices Vs. Communicating Software
I once interviewed a gung-ho pro-EMR doctor who was building a Regional Heath Information Organization (RHIO) allowing medical groups, hospitals, businesses, and patients to communicate. He said current EMRs are nothing but Giant Invoices used by payers to document what doctors do. “Wouldn’t it be wonderful,” he said, “if we could use EMRs to talk to one another?” Until then, EMRs are of marginal utility to doctors and patients.
4) Virtual Vs. Face-to-Face Realities
In the IT world, virtual means something generated by a computer to simulate reality for reasons of economics, convenience or performance. Examples in the physician world would be computer interviewing of patients prior to seeing the doctor, judging the need for erectile dysfunction drugs through an online history questionnaire, or virtual colonoscopies without rectal colonoscopy. Doctors resist the notion that computers can substitute for them in taking a history, and drug companies fight the concept that anything could replace a person-to-person prescribing doctor. Regulatory agencies will have to decide.
5) Online Practice
In my experience, young entrepreneurial doctors embrace the idea that they practice medicine online - getting referrals online, documenting payers online, setting up appointments online, referring patients to others online, communicating with patients online, getting diagnostic support information online, communicating with patients online, and collecting fees online. A staff and an office may not even be needed. These types of practices remain rare, and most physicians remain leery of anything done without seeing the patient.
6) Big Brother is Watching You.
The mainstream use of sophisticated algorithms to slice, dice, analyzes, aggregate, predict, customize, and personalize clinical data to judge the performance and value of physicians, to intervene clinically, and to steer patients to specialists offering the best care, using the “best practices,” and practicing “evidence-based medicine” is now a major industry, particularly among major health systems and health payers. The major problem among physicians of this electronic onslaught is that the data may be used against them without knowledge of its limits and complexities of human interactions and desires for the best individual choices on the ground. Algorithms can never track all the subtleties of the more than 2 billion health care transactions that occur at the site of care. IT intervention and analysis has limits, freedom of choice is still important, and it is arrogant to think otherwise
References
1. Mark Munger and others, "Safety of Prescribing PDE5 Inhibitors, via e-medicine, vs Traditional Medicine," Mayo Clinic Proceedings, August, 2008m pages 890-896
2. Richard Reece, New Parksinons’s Law: No office, No Staff, No Bureaucracy, No Problem, www.mediinnovationblog.blogspot.com, April 10, 2008.
C.P. Snow, New York Times, 1971
To know and not to do is not to do; Knowledge does become power until it is used.
Harvey McKay, Swim with the Sharks without Being Eaten Alive
Big Brother is watching you.
George Orwell, 1984
To hear Health 2.0 and Health 3.0 seers tell it, Internet medicine is already upon us and will revolutionize medicine.
But for physicians, Internet medicine has yet to prove itself. The Internet may bring great gifts, but it brings trouble too and often does not translate into human terms or address practical practice problems. In its current state, most information technology (IT) does not bring useful clinical knowledge, and it is used more for clinical surveillance than advancing care. Physicians do not use much of this new knowledge, and it remains fallow information.
This, in essence, is what I told a reporter who interviewed me for The Record Magazine, an online publication for IT health care professionals.
Here are a few of my thoughts on why Internet Medicine adoption is so slow.
1) Elephant in the Room
Before resigning as President Bush’s health information czar, David Brailer, M.D., said small physician practices were the elephant in the room – the main obstacle blocking progress toward a national interoperable functioning system. He was right. Small practices do not have money, time, and human resources to install and adopt EMRs that disrupt practice flow, show return on investment, or tangible incentives for using. These are some of the reasons why only 4% of doctors have fully functioning EMRs and only 14% have basic EMRs. Until IT gurus walk in the doctors’ moccasins, they will be like blind men feeling the elephants.
2) Hammers and Nails
Two thirds of U.S. doctors are specialists. Medical specialists have a hammer – a set of skills – to hit a nail – to perform procedures for patients who need those skills. IT specialists also have a hummer – computer software – and they also have a nail to hit – building software to minimize: unneeded procedures. IT specialists sometime forget. The suffer from funnel vision and forget that every specialty has different EMR needs. Conflicts are inevitable, and medical specialists will be skeptical and even hostile towards IT specialists.
3) Giant Invoices Vs. Communicating Software
I once interviewed a gung-ho pro-EMR doctor who was building a Regional Heath Information Organization (RHIO) allowing medical groups, hospitals, businesses, and patients to communicate. He said current EMRs are nothing but Giant Invoices used by payers to document what doctors do. “Wouldn’t it be wonderful,” he said, “if we could use EMRs to talk to one another?” Until then, EMRs are of marginal utility to doctors and patients.
4) Virtual Vs. Face-to-Face Realities
In the IT world, virtual means something generated by a computer to simulate reality for reasons of economics, convenience or performance. Examples in the physician world would be computer interviewing of patients prior to seeing the doctor, judging the need for erectile dysfunction drugs through an online history questionnaire, or virtual colonoscopies without rectal colonoscopy. Doctors resist the notion that computers can substitute for them in taking a history, and drug companies fight the concept that anything could replace a person-to-person prescribing doctor. Regulatory agencies will have to decide.
5) Online Practice
In my experience, young entrepreneurial doctors embrace the idea that they practice medicine online - getting referrals online, documenting payers online, setting up appointments online, referring patients to others online, communicating with patients online, getting diagnostic support information online, communicating with patients online, and collecting fees online. A staff and an office may not even be needed. These types of practices remain rare, and most physicians remain leery of anything done without seeing the patient.
6) Big Brother is Watching You.
The mainstream use of sophisticated algorithms to slice, dice, analyzes, aggregate, predict, customize, and personalize clinical data to judge the performance and value of physicians, to intervene clinically, and to steer patients to specialists offering the best care, using the “best practices,” and practicing “evidence-based medicine” is now a major industry, particularly among major health systems and health payers. The major problem among physicians of this electronic onslaught is that the data may be used against them without knowledge of its limits and complexities of human interactions and desires for the best individual choices on the ground. Algorithms can never track all the subtleties of the more than 2 billion health care transactions that occur at the site of care. IT intervention and analysis has limits, freedom of choice is still important, and it is arrogant to think otherwise
References
1. Mark Munger and others, "Safety of Prescribing PDE5 Inhibitors, via e-medicine, vs Traditional Medicine," Mayo Clinic Proceedings, August, 2008m pages 890-896
2. Richard Reece, New Parksinons’s Law: No office, No Staff, No Bureaucracy, No Problem, www.mediinnovationblog.blogspot.com, April 10, 2008.
Tuesday, August 12, 2008
Physician payment - Are Doctors Paid Enough?
When asked, “Do doctors make too much money?”, the wife of a well-known Minneapolis surgeon, used to reply, “They don’t make enough..”
With her reply in mind, I bring your attention to a July 17 piece in www.healthleadersmedia.com. “Are Doctors Underpaid?’ In it, Phillip Miller, vice-president of communication for Merritt Hawkins & Associates, a physician search firm, a division of AMN Healthcare, Inc, argues that while certain specialists are paid well, most primary care practitioners are not.
Miller observes.
• In 2007, salaries offered certified nurse anesthetists ($185,000) exceeded those of general internists ($176,000), family physicians ($172,000), and pediatricians ($159.000).
• Salaries offered to orthopedic surgeons, radiologists, and cardiologists, averaged $408,000 and surpassed average salaries offered to general internists, family physicians, and pediatricians ($169,000) by a factor of nearly 2 ½ to one.- a striking disparity fueling the primary are shortage.
• Among government and private plan officials, the pressure to cut physician reimbursement is unremitting because these officials know the public will not object because of the perception that most doctors are wealthy (as an aside, I don’t believe this belief will change until access to care is sharply cut).
• Many doctors, particularly primary care physicians, can argue with justification they are underpaid, given their educational debt of $150,000 or more, their 11 years or more of collegiate and post-collegiate education, their high malpractice premiums, and their relentless rising practice costs, many secondary to rules and regulations.
• Given the benefits they bring to society, physicians provide services worthy of high rewards, compared to more highly paid professionals.
• Doctors other than primary care physicians cannot argue they are underpaid (they rank in the upper middle class in income), but most doctors in all practice categories suffer from under empowerment -
unable to raise fees, submitting bills to third parties that are often not paid, and unable to pursue a course of treatment that must be approved by someone far removed from the treatment scene.
• Many physicians are looking for a way out of traditional practice settings – by taking non-clinical jobs, retiring, working as temps. And avoiding third parties by accepting only direct payment.
I recommend you read the full-text of Miller’s message by going to www.healthleadersmedia.com or respond to him directly at pmiller@mha.com.
With her reply in mind, I bring your attention to a July 17 piece in www.healthleadersmedia.com. “Are Doctors Underpaid?’ In it, Phillip Miller, vice-president of communication for Merritt Hawkins & Associates, a physician search firm, a division of AMN Healthcare, Inc, argues that while certain specialists are paid well, most primary care practitioners are not.
Miller observes.
• In 2007, salaries offered certified nurse anesthetists ($185,000) exceeded those of general internists ($176,000), family physicians ($172,000), and pediatricians ($159.000).
• Salaries offered to orthopedic surgeons, radiologists, and cardiologists, averaged $408,000 and surpassed average salaries offered to general internists, family physicians, and pediatricians ($169,000) by a factor of nearly 2 ½ to one.- a striking disparity fueling the primary are shortage.
• Among government and private plan officials, the pressure to cut physician reimbursement is unremitting because these officials know the public will not object because of the perception that most doctors are wealthy (as an aside, I don’t believe this belief will change until access to care is sharply cut).
• Many doctors, particularly primary care physicians, can argue with justification they are underpaid, given their educational debt of $150,000 or more, their 11 years or more of collegiate and post-collegiate education, their high malpractice premiums, and their relentless rising practice costs, many secondary to rules and regulations.
• Given the benefits they bring to society, physicians provide services worthy of high rewards, compared to more highly paid professionals.
• Doctors other than primary care physicians cannot argue they are underpaid (they rank in the upper middle class in income), but most doctors in all practice categories suffer from under empowerment -
unable to raise fees, submitting bills to third parties that are often not paid, and unable to pursue a course of treatment that must be approved by someone far removed from the treatment scene.
• Many physicians are looking for a way out of traditional practice settings – by taking non-clinical jobs, retiring, working as temps. And avoiding third parties by accepting only direct payment.
I recommend you read the full-text of Miller’s message by going to www.healthleadersmedia.com or respond to him directly at pmiller@mha.com.
Sunday, August 10, 2008
Primary Care, Variations off the Main Theme
The Foundation for Health System Excellence, representing physicians in state and local medical societies, has just completed a national survey of all U.S. primary care physicians, the results of which are being tabulated, to be released when ready.
I would like to examine variations off the main theme, the main theme being primary care clinicians practicing by themselves and under the thumb of managed care insurers. There are roughly 300,000 primary care physicians – family physicians, general internists, pediatricians, most of whom treat insured, Medicare, or Medicaid patients
Physician Assistants and Nurse Practitioners
Primary care doctors are in short supply, maybe on the verge of extinction; even though policy experts assert these doctors form the backbone of national health systems. Many primary care doctors seek to survive by hiring and working with physician assistants (PAs) and nurse practitioners (NPs). Since 2001, PA numbers have grown from 43,000 to 68,000, and NPs from 82,000 to 125,000.
PA and NP salaries are in the $85,000 to $90,000 range, a pretty penny for many struggling primary care practices. Their roles differ. PAs must practice under a physician’s supervision. NPs may practice independently, though most do not. PAs tend to work for generalists, NPs for specialists. In the last 5 years, NPs have rapidly risen to prominence for staffing retail clinics, now numbering about 1000.
Nurse Doctors, Another Variation Off the Theme
In 2004, the American Association of Colleges of Nurses recommended new NPs, who now have masters degrees, earn a doctor of nursing by 2015. The Columbia School of Nursing offered the degree in 2005. Now 74 nursing schools do, and 63 more have programs in the works. Doctor nurses may practice independently, prescribe, treat patients on their own, and join medical staffs. They are intended to supplement, even replace, primary care practitioners.
Prepaid and Cash Only Primary Care
Yet another variation off the traditional theme are generalist doctors who drop out of Medicare, insurance plans, and third party programs. These clinicians, who many in the elite medical establishment consider mavericks, treat patients on the basis of a prepaid retainers, generally $1000 to $2000 annually, which may be paid in quarterly installments, or on the basis of discounted “cash-only” fees, often 50% less than current fees.
Critics may label prepaid primary care as luxury, concierge, platinum, boutique, VIP, or two-tier care, the implication being practices cater only to the wealthy. “Cash-only” practitioners call their services direct, patient-financed, simple, innovative, or payment at the point of service. These practices serve all comers, including the uninsured, underserved, or those unhappy with the present system.
Common Distaste
Pre-paid primary care retainer practices and the cash only crowd share a distaste for practices beholden to insurers, practice restrictions, staff and other overhead required to process claims, low and delayed reimbursements, entangling bureaucracies, and for the assembly-line care they must provide to break even.
Marcus Welby Reincarnate
Both may say their care represents a re-incarnation of Marcus Welby, with more time, greater access, and closer patient relationships. Prepaid practitioners limit their base to 350 to 500 patients, down from current loads of 2000 to 2500 patients. Cash-only clinicians do not restrict numbers of patients, some of whom may be transient. Services for retainer practices may include unlimited doctor access,24 hours a day, 365 days a year; unlimited telephone and e-mail access, uninterrupted time with physicians, annual lab work,EKG and hearing evaluation, coordinating care,
navigating patients through the medical maze, and referral to top specialists. Cash-only doctors generally offer across-the board discounts for most services.
How Many Prepaid or “Cash-Only” Practices Are There?
It’s hard to tell. The practices go by different names, and they may or may not belong to associations. Their practices may be controversial, and they often assume a low profile posture.. Retainer practices limit rather than expand practices, so no need exists to to market. The Society of Innovative Medical Practice Design (SIMPD.org) an umbrella term that generally implies concierge practices, says its members practice in about 30 states and covers over 100,000 patients. SimpleCare, Inc, in Renton, Washington, which has a fee-for-service fee schedule for short, medium, and long visits, claims it has a national network of 1600 physicians.
In my book, Innovation-Driven Health Care(Jones and Bartlett, 2007), I observed,
” The number primary care physicians leaving traditional practice is a precious few. I estimate their numbers at less than 1% of practicing physicians, although I can find no single source to document their actual numbers. The success of these practices depends on the willingness of patients to pay out of pocket for more personal, more convenient care.”
I would like to examine variations off the main theme, the main theme being primary care clinicians practicing by themselves and under the thumb of managed care insurers. There are roughly 300,000 primary care physicians – family physicians, general internists, pediatricians, most of whom treat insured, Medicare, or Medicaid patients
Physician Assistants and Nurse Practitioners
Primary care doctors are in short supply, maybe on the verge of extinction; even though policy experts assert these doctors form the backbone of national health systems. Many primary care doctors seek to survive by hiring and working with physician assistants (PAs) and nurse practitioners (NPs). Since 2001, PA numbers have grown from 43,000 to 68,000, and NPs from 82,000 to 125,000.
PA and NP salaries are in the $85,000 to $90,000 range, a pretty penny for many struggling primary care practices. Their roles differ. PAs must practice under a physician’s supervision. NPs may practice independently, though most do not. PAs tend to work for generalists, NPs for specialists. In the last 5 years, NPs have rapidly risen to prominence for staffing retail clinics, now numbering about 1000.
Nurse Doctors, Another Variation Off the Theme
In 2004, the American Association of Colleges of Nurses recommended new NPs, who now have masters degrees, earn a doctor of nursing by 2015. The Columbia School of Nursing offered the degree in 2005. Now 74 nursing schools do, and 63 more have programs in the works. Doctor nurses may practice independently, prescribe, treat patients on their own, and join medical staffs. They are intended to supplement, even replace, primary care practitioners.
Prepaid and Cash Only Primary Care
Yet another variation off the traditional theme are generalist doctors who drop out of Medicare, insurance plans, and third party programs. These clinicians, who many in the elite medical establishment consider mavericks, treat patients on the basis of a prepaid retainers, generally $1000 to $2000 annually, which may be paid in quarterly installments, or on the basis of discounted “cash-only” fees, often 50% less than current fees.
Critics may label prepaid primary care as luxury, concierge, platinum, boutique, VIP, or two-tier care, the implication being practices cater only to the wealthy. “Cash-only” practitioners call their services direct, patient-financed, simple, innovative, or payment at the point of service. These practices serve all comers, including the uninsured, underserved, or those unhappy with the present system.
Common Distaste
Pre-paid primary care retainer practices and the cash only crowd share a distaste for practices beholden to insurers, practice restrictions, staff and other overhead required to process claims, low and delayed reimbursements, entangling bureaucracies, and for the assembly-line care they must provide to break even.
Marcus Welby Reincarnate
Both may say their care represents a re-incarnation of Marcus Welby, with more time, greater access, and closer patient relationships. Prepaid practitioners limit their base to 350 to 500 patients, down from current loads of 2000 to 2500 patients. Cash-only clinicians do not restrict numbers of patients, some of whom may be transient. Services for retainer practices may include unlimited doctor access,24 hours a day, 365 days a year; unlimited telephone and e-mail access, uninterrupted time with physicians, annual lab work,EKG and hearing evaluation, coordinating care,
navigating patients through the medical maze, and referral to top specialists. Cash-only doctors generally offer across-the board discounts for most services.
How Many Prepaid or “Cash-Only” Practices Are There?
It’s hard to tell. The practices go by different names, and they may or may not belong to associations. Their practices may be controversial, and they often assume a low profile posture.. Retainer practices limit rather than expand practices, so no need exists to to market. The Society of Innovative Medical Practice Design (SIMPD.org) an umbrella term that generally implies concierge practices, says its members practice in about 30 states and covers over 100,000 patients. SimpleCare, Inc, in Renton, Washington, which has a fee-for-service fee schedule for short, medium, and long visits, claims it has a national network of 1600 physicians.
In my book, Innovation-Driven Health Care(Jones and Bartlett, 2007), I observed,
” The number primary care physicians leaving traditional practice is a precious few. I estimate their numbers at less than 1% of practicing physicians, although I can find no single source to document their actual numbers. The success of these practices depends on the willingness of patients to pay out of pocket for more personal, more convenient care.”
Saturday, August 9, 2008
Hospitals and physicians - Hospital Funnel Vision, Market Myopia, and the Great Migration
What: Hospitals profit and admission growth is relentlessly slowing because of combination of “market myopia” and patients migrating to out-of-hospital settings. 1, 2
Why: Because hospitals look at the marketing too narrowly. Instead they keep pouring their capital into expanding their on-campus buildings and services “inside” rather than acknowledging patients are searching for cheaper care and disruptive innovations “outside.” This may be because hospitals have been King of the Health Care Mountain for so long, they can’t see the Barbarians and the Gates.
How: Drop in “inside growth” and admissions occurring because of “outside growth” of less costly and more convenient ambulatory surgical, imaging, multispecialty care, urgent care centers; retail and worksite clinics; detached emergency rooms, specialty clinics, pre-paid and discounted pay at time of service practices, medical tourism and global health care, and disruptive innovations that make care deliverable in homes or without overnight hospital stays.
Where: Where are have the patients gone? Everywhere, to all of the above, because consumers have heard of well-publicized hospital horrors, scandalously high hospital pricing, long waits in emergency rooms, and growing numbers of out-of-hospital options.
Who: Who is responsible for “funnel vision,” dropping growth rates, and outward migration?
Hospital executives, who see the world through the eyes of their own real estate.
Consumers, certainly. They are looking for cheaper, more convenient, and more affordable care not requiring overnight hospital stays and removed from hospital safety hazards.
Physicians, too. They prefer controlling clinical care in their own owned-facilities.
Entrepreneurs, who are actively seeking and investing in new outpatient niches.
Real estate operators, who are only too willing to fill their vacancies with recession-proof health care businesses.
Also it becoming evident, even among liberal reformers, that reform-driven expanded coverage will occur within a market framework and that costs will shift to consumers, who will want more choices, usually outside of hospitals.
Sooner and later, hospital executives will realize patients and revenues are no longer funneling into hospitals. They will begin to know the truth of the maxim,” Old hospital executive never die, they just lose their facilities.
References
1. Preston Gee, “Funnel Vision: Do Health Leaders Have Delivery System Myopia,” Healthleadersmedia.com, August 6, 12008.
2. “Value at the Center: The State of Our Industry- 2007” Advisory Board Report, The Advisory Board Company, Washington, D.C.
Why: Because hospitals look at the marketing too narrowly. Instead they keep pouring their capital into expanding their on-campus buildings and services “inside” rather than acknowledging patients are searching for cheaper care and disruptive innovations “outside.” This may be because hospitals have been King of the Health Care Mountain for so long, they can’t see the Barbarians and the Gates.
How: Drop in “inside growth” and admissions occurring because of “outside growth” of less costly and more convenient ambulatory surgical, imaging, multispecialty care, urgent care centers; retail and worksite clinics; detached emergency rooms, specialty clinics, pre-paid and discounted pay at time of service practices, medical tourism and global health care, and disruptive innovations that make care deliverable in homes or without overnight hospital stays.
Where: Where are have the patients gone? Everywhere, to all of the above, because consumers have heard of well-publicized hospital horrors, scandalously high hospital pricing, long waits in emergency rooms, and growing numbers of out-of-hospital options.
Who: Who is responsible for “funnel vision,” dropping growth rates, and outward migration?
Hospital executives, who see the world through the eyes of their own real estate.
Consumers, certainly. They are looking for cheaper, more convenient, and more affordable care not requiring overnight hospital stays and removed from hospital safety hazards.
Physicians, too. They prefer controlling clinical care in their own owned-facilities.
Entrepreneurs, who are actively seeking and investing in new outpatient niches.
Real estate operators, who are only too willing to fill their vacancies with recession-proof health care businesses.
Also it becoming evident, even among liberal reformers, that reform-driven expanded coverage will occur within a market framework and that costs will shift to consumers, who will want more choices, usually outside of hospitals.
Sooner and later, hospital executives will realize patients and revenues are no longer funneling into hospitals. They will begin to know the truth of the maxim,” Old hospital executive never die, they just lose their facilities.
References
1. Preston Gee, “Funnel Vision: Do Health Leaders Have Delivery System Myopia,” Healthleadersmedia.com, August 6, 12008.
2. “Value at the Center: The State of Our Industry- 2007” Advisory Board Report, The Advisory Board Company, Washington, D.C.
Friday, August 8, 2008
Quality, pay for performance - P4P Impact and Quality: Irrational Exuberance?
What: July/August 2008 Health Affairs article, “The Impact of Pay-for-Performance on Health Care Quality in Massachusetts, 2001-2003,” Samuel Pearson, et al, volume 27, No. 4, pages 1167-1776. Study involved 81 Massachusetts physician groups following P4P guidelines and 73 groups who did not. Overall, performance improved by 73%, but no distinguishable differences existed between participating and non-participating groups.
Why: Because P4P has been all the rage as a powerful incentive to persuade doctors to institute and follow quality indicators. Implications are that that P4P may not be end solution for quality that P4P advocates may be suffering from excessive exuberance, that bonuses had no effect on physician performance, and that “Future research is required to determine whether changes in the magnitude, structure, and alignment of P4P incentives can lead to improved care.”
How: By giving doctors financial incentives consisting of bonuses, generally about 5% of total compensation, sometimes as high as 10%, for recording and implementing performance measures.
When: Last ten years, led by California’s Integrated Health Healthcare Association, consisting of collaborating health plans, physician groups, and hospitals, with 40,000 doctors participating.
Where: Wherever health plans offer P4P programs. 150 plans in effect, most notable in regions where managed care dominates, e.g. California, Northwest, upper Midwest, East Coast, heavily populated metropolitan areas anywhere.
Who: Study included 5 commercial health plans contracting with 90% of Massachusetts practicing primary care physicians and performance measures such Hemoglobin A1C testing, br3at cancer screening, diabetic eye exams, LDL-cholesterol screening, diabetic eye exams, and well-child visits. Lead author Steven Pearson, MD, commented, “Unless you look at a control group of some kind, you may be misleading about what’s really happening.” In another study, Oct, 12, 2005, investigators found California physicians did better on only one measure – cervical cancer screening – than a comparison group of Oregon physicians. Says Meredith Rosenthal, MD, lead author of that study, “We actually have remarkably few evolutions that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty. The programs we’ve evaluated over the last five years have been largely unimpressive in their results.”
Why: Because P4P has been all the rage as a powerful incentive to persuade doctors to institute and follow quality indicators. Implications are that that P4P may not be end solution for quality that P4P advocates may be suffering from excessive exuberance, that bonuses had no effect on physician performance, and that “Future research is required to determine whether changes in the magnitude, structure, and alignment of P4P incentives can lead to improved care.”
How: By giving doctors financial incentives consisting of bonuses, generally about 5% of total compensation, sometimes as high as 10%, for recording and implementing performance measures.
When: Last ten years, led by California’s Integrated Health Healthcare Association, consisting of collaborating health plans, physician groups, and hospitals, with 40,000 doctors participating.
Where: Wherever health plans offer P4P programs. 150 plans in effect, most notable in regions where managed care dominates, e.g. California, Northwest, upper Midwest, East Coast, heavily populated metropolitan areas anywhere.
Who: Study included 5 commercial health plans contracting with 90% of Massachusetts practicing primary care physicians and performance measures such Hemoglobin A1C testing, br3at cancer screening, diabetic eye exams, LDL-cholesterol screening, diabetic eye exams, and well-child visits. Lead author Steven Pearson, MD, commented, “Unless you look at a control group of some kind, you may be misleading about what’s really happening.” In another study, Oct, 12, 2005, investigators found California physicians did better on only one measure – cervical cancer screening – than a comparison group of Oregon physicians. Says Meredith Rosenthal, MD, lead author of that study, “We actually have remarkably few evolutions that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty. The programs we’ve evaluated over the last five years have been largely unimpressive in their results.”
Thursday, August 7, 2008
Physician business ideas, physician business models - Urgent Care Clinics
What: Urgent Care Clinics, 8000 of them, 1200 affiliated with hospitals.
Why: Numbers are growing as less expensive and more convenient alternative to overcrowded ERs, and as places staffed by physicians who can do things nurse practitioners cannot do in retails clinics.
How: Have staff to equipment to cast broken bones, put on splints, sew up lacerations, give IVs for dehydration, treat burns, remove foreign bodies, and offer life support and transportation. Pricing varies: Level 1 - $79 for visit, no diagnostic tests or procedures; Level 2 - $129 for one procedure – sewing up laceration, removing sutures, treating minor burns, rmoeval of foreign body, treating eye injury; Level 3 –Performing more than one procedure, injections, IVs for dehydration
When: Evolving in sophistication and scope and growing in numbers for last 20 years, largely in response to fewer, more overcrowded, and more expensive ERs, with longer waits and bigger bills ($1000 vs. $60 to $200) and as alternative to long waits at swamped primary care offices.
Where: Strip malls, next to highways, rural areas, near hospitals.
Who: Staffed by family physicians and Emergency doctors, backed by URgen Care Associatons, covered by many insurers, owned by Solantic, Inc, of Jacksonville, Florida, Nextcare of Mesa, Arizone, doctors, investors, and hospitals.
Reference: Laura Landro, “Options Expand for Avoiding Crowed ERs, “ Wall Street Journal, August 6, 2008
Why: Numbers are growing as less expensive and more convenient alternative to overcrowded ERs, and as places staffed by physicians who can do things nurse practitioners cannot do in retails clinics.
How: Have staff to equipment to cast broken bones, put on splints, sew up lacerations, give IVs for dehydration, treat burns, remove foreign bodies, and offer life support and transportation. Pricing varies: Level 1 - $79 for visit, no diagnostic tests or procedures; Level 2 - $129 for one procedure – sewing up laceration, removing sutures, treating minor burns, rmoeval of foreign body, treating eye injury; Level 3 –Performing more than one procedure, injections, IVs for dehydration
When: Evolving in sophistication and scope and growing in numbers for last 20 years, largely in response to fewer, more overcrowded, and more expensive ERs, with longer waits and bigger bills ($1000 vs. $60 to $200) and as alternative to long waits at swamped primary care offices.
Where: Strip malls, next to highways, rural areas, near hospitals.
Who: Staffed by family physicians and Emergency doctors, backed by URgen Care Associatons, covered by many insurers, owned by Solantic, Inc, of Jacksonville, Florida, Nextcare of Mesa, Arizone, doctors, investors, and hospitals.
Reference: Laura Landro, “Options Expand for Avoiding Crowed ERs, “ Wall Street Journal, August 6, 2008
Wednesday, August 6, 2008
Data, use and misuse- Contrawise: Confessions of A Data Contrarian
“Contrawise,” continued Tweedledee, “if it was so, it might be, and if it were so, it would be, but as it isn’t, it ain’t. That’s logic.”
Lewis Carroll, 1832-1898, Alice in Wonderland, “The Jabberwocky”
As I write, I’m swimming upstream against downstream logic. The logic goes like this: If data says it’s so, it must be. Data doesn’t lie. Trust intuition: All others use data, please. Data isn’t a question of would be, or might be, it’s so.
Yet reasons exist for doubting raw application of health information technology and data as keys to effective quality improvement.
1. In human endeavors, psychology and supply and demand trump data, charts, statistical trends or analyses. Look no further than stock markets, “laws of economics, ”or gas prices.
2. Vagaries of human interaction and returns of patients to bad health habits are more likely to determine outcomes than adhering to data-based protocols or what occurred during doctor visits or hospital stays.
3. For 30 years, John Wennberg and followers at Dartmouth and Harvard have lamented regional data care variations without notable effect. Culture, not medical malfeasance, dictates the differences. Data has not “corrected” or “narrowed” these differences.
4. Pick of the litter medical centers – Johns Hopkins, Mayo, Cleveland Clinic, Harvard Hospitals, Columbia Presbyterian – vary greatly in lengths of stay, number of specialists consulted, and outcomes. These factors are more a function of patient bases, severity of illnesses and institutional and regional environments, than data deviations.
5. Procedure use often depends on subjective factors – such as demands for knee or hip replacements to maintain an active life style. Deploying data to justify these procedures is unlikely to curtail demand or to stop specialists from doing procedures. Patients will shop around. They will find someone who will do what they think needs to be done. There are always ways around data, as in cash only practices or cosmetic procedures not covered by insurance.
6. It takes money to make data – as much as $50,000 per doctor per year to create, maintain, and monitor data. It is said ubiquitous EMRs and robust data-based infrastructures will save 20% of our national health bill. The flip side of this cost equation is seldom mentioned.
7. Controlling medical decision making is a tricky and complicated proposition. Data does always reflect this “trickiness” and “complicatedness.” Medical care is full of paradoxes and tensions, “right degrees” of information flow, diversity and differences, connections inside and outside the practice, and between patient and doctor. These all involve balancing intuition and data, safety and risk. Government and management cannot control or even track the 2 billion health marketplace transactions.
8. Supply and demand for innovative technologies, hospital “marketing wars,“ media reports of technology wonders, consumers seeking miracle cures or relief, are difficult to regulate, assess, and suppress. Some policies makers say government should require technological assessments before market introductions. It will not work. You cannot bottle up or block entrepreurship, innovation, and sheer human inventiveness. There’s always a better way, and people will find it.
9. Data-advocates should be more modest in over-estimating their limitations and their abilities to reduce “unnecessary procedures,” enhance necessary clinical conduct, and transform human nature at the point of care. We live in a button-up, not a top-down, society.
10. Some approaches to quality improvement are worthwhile. Data can be useful when shared, compared, aggregated, analyzed, sliced, and diced, but data has profound limitations. It is but one small arrow in the quality quiver and has limits in deciphering deficits and exposing excesses/
David Nash, MD, professor and chairman of the Department of Health Policy at Jefferson Medical College. is an articulate spokesman for the value of data-gathering technologies. He edits two publications, Health Policy Newsletter and Prescriptions for Excellence in Health Care, the latter in collaboration with Eli Lilly and Company. These newsletters champion performance improvement methodologies, evidence-based medicine, and comprehensive data-driven support systems to establish comprehensive clinical safety and quality. I salute his efforts, particularly his promotion of the “scholarship of quality.” W need more quality scholars.
Data systems may increase safety and quality, but they are expensive and limited in their capacity to change fundamental human nature or outpatient medical practices. Most physicians to whom I have spoken say that quality control measures have yet to significantly influenced practice. That influence may come, but we are not there yet.
Lewis Carroll, 1832-1898, Alice in Wonderland, “The Jabberwocky”
As I write, I’m swimming upstream against downstream logic. The logic goes like this: If data says it’s so, it must be. Data doesn’t lie. Trust intuition: All others use data, please. Data isn’t a question of would be, or might be, it’s so.
Yet reasons exist for doubting raw application of health information technology and data as keys to effective quality improvement.
1. In human endeavors, psychology and supply and demand trump data, charts, statistical trends or analyses. Look no further than stock markets, “laws of economics, ”or gas prices.
2. Vagaries of human interaction and returns of patients to bad health habits are more likely to determine outcomes than adhering to data-based protocols or what occurred during doctor visits or hospital stays.
3. For 30 years, John Wennberg and followers at Dartmouth and Harvard have lamented regional data care variations without notable effect. Culture, not medical malfeasance, dictates the differences. Data has not “corrected” or “narrowed” these differences.
4. Pick of the litter medical centers – Johns Hopkins, Mayo, Cleveland Clinic, Harvard Hospitals, Columbia Presbyterian – vary greatly in lengths of stay, number of specialists consulted, and outcomes. These factors are more a function of patient bases, severity of illnesses and institutional and regional environments, than data deviations.
5. Procedure use often depends on subjective factors – such as demands for knee or hip replacements to maintain an active life style. Deploying data to justify these procedures is unlikely to curtail demand or to stop specialists from doing procedures. Patients will shop around. They will find someone who will do what they think needs to be done. There are always ways around data, as in cash only practices or cosmetic procedures not covered by insurance.
6. It takes money to make data – as much as $50,000 per doctor per year to create, maintain, and monitor data. It is said ubiquitous EMRs and robust data-based infrastructures will save 20% of our national health bill. The flip side of this cost equation is seldom mentioned.
7. Controlling medical decision making is a tricky and complicated proposition. Data does always reflect this “trickiness” and “complicatedness.” Medical care is full of paradoxes and tensions, “right degrees” of information flow, diversity and differences, connections inside and outside the practice, and between patient and doctor. These all involve balancing intuition and data, safety and risk. Government and management cannot control or even track the 2 billion health marketplace transactions.
8. Supply and demand for innovative technologies, hospital “marketing wars,“ media reports of technology wonders, consumers seeking miracle cures or relief, are difficult to regulate, assess, and suppress. Some policies makers say government should require technological assessments before market introductions. It will not work. You cannot bottle up or block entrepreurship, innovation, and sheer human inventiveness. There’s always a better way, and people will find it.
9. Data-advocates should be more modest in over-estimating their limitations and their abilities to reduce “unnecessary procedures,” enhance necessary clinical conduct, and transform human nature at the point of care. We live in a button-up, not a top-down, society.
10. Some approaches to quality improvement are worthwhile. Data can be useful when shared, compared, aggregated, analyzed, sliced, and diced, but data has profound limitations. It is but one small arrow in the quality quiver and has limits in deciphering deficits and exposing excesses/
David Nash, MD, professor and chairman of the Department of Health Policy at Jefferson Medical College. is an articulate spokesman for the value of data-gathering technologies. He edits two publications, Health Policy Newsletter and Prescriptions for Excellence in Health Care, the latter in collaboration with Eli Lilly and Company. These newsletters champion performance improvement methodologies, evidence-based medicine, and comprehensive data-driven support systems to establish comprehensive clinical safety and quality. I salute his efforts, particularly his promotion of the “scholarship of quality.” W need more quality scholars.
Data systems may increase safety and quality, but they are expensive and limited in their capacity to change fundamental human nature or outpatient medical practices. Most physicians to whom I have spoken say that quality control measures have yet to significantly influenced practice. That influence may come, but we are not there yet.
Tuesday, August 5, 2008
Physican Leadership - Why Doctors Voices Are Not Heard: Is It Because?
Why is it as health reform moves forward, doctors’ voices aren’t heard. If you give the matter any thought at all, you will realize others – politicians, policy wonks, health plans, drug companies, and other big health care organizational vested interests dominate the reform discourse?
Why Is It?
Why is it doctors, who are demoralized, about the direction and tone of the health system, aren’t heard? After all, doctors, with the possible exception of new breeds of nurse practitioners and “nurse-doctors,” remain the ones licensed to “practice medicine.” Society depends on us, indeed, licenses us to “deliver care.”
Is It Because
Is it because, physicians are considered,
• to be a “privileged class,” deserving no more than they already have?;
• to make too money already?;
• to be “autonomous” mavericks stuck in their ways and resistant to change?;
• to be small disorganized small businessmen, and therefore easy prey for large corporations?
Is it because, of physicians’
• tendencies to focus on their own profession, to have tunnel vision, and to ignore the interests of society at large?;
• failures to develop a more efficient, safer business model, such as “medical homes?”;
• ineffectiveness in addressing the notion that doctors are primarily responsible for high health costs?
Is it because physicians,
• have knuckled under to managed care, which has forced doctors to see more patients at lower reimbursements, leading to patient mistrust of doctors; who have less time to spend with them?;
• have permitted HMOs and health plans to hijack the primary function of doctors – caring for patients;
• have not had the sense to recognize Americans entrust health care and almost everything else to the marketing, administrative, and informational power of large organizations?
Is it because,
• Internet information, good and bad, has placed patients doctors on a more level playing field, making doctors seem more like ordinary mortals – incapable of knowing everything?;
• physicians have not taken a more proactive lead in establishing systems to assure quality and safety;
• physicians have not been more innovative by consulting organizations outside of medicine on how to please and deal with busy consumers in the course of their daily lives.
Or is it because,
• Physicians are the most visible symbol of a dysfunctional health system, for it they who deliver the care, and it is they who shoulder the expenses imposed upon them?;
• the public and their to-down leaders have ignored the impossible pressures and unreasonable bureaucratic demands being placed on physicians without supplying them with the incentives and resources required to deal with those demands?
Why Is It?
Why is it doctors, who are demoralized, about the direction and tone of the health system, aren’t heard? After all, doctors, with the possible exception of new breeds of nurse practitioners and “nurse-doctors,” remain the ones licensed to “practice medicine.” Society depends on us, indeed, licenses us to “deliver care.”
Is It Because
Is it because, physicians are considered,
• to be a “privileged class,” deserving no more than they already have?;
• to make too money already?;
• to be “autonomous” mavericks stuck in their ways and resistant to change?;
• to be small disorganized small businessmen, and therefore easy prey for large corporations?
Is it because, of physicians’
• tendencies to focus on their own profession, to have tunnel vision, and to ignore the interests of society at large?;
• failures to develop a more efficient, safer business model, such as “medical homes?”;
• ineffectiveness in addressing the notion that doctors are primarily responsible for high health costs?
Is it because physicians,
• have knuckled under to managed care, which has forced doctors to see more patients at lower reimbursements, leading to patient mistrust of doctors; who have less time to spend with them?;
• have permitted HMOs and health plans to hijack the primary function of doctors – caring for patients;
• have not had the sense to recognize Americans entrust health care and almost everything else to the marketing, administrative, and informational power of large organizations?
Is it because,
• Internet information, good and bad, has placed patients doctors on a more level playing field, making doctors seem more like ordinary mortals – incapable of knowing everything?;
• physicians have not taken a more proactive lead in establishing systems to assure quality and safety;
• physicians have not been more innovative by consulting organizations outside of medicine on how to please and deal with busy consumers in the course of their daily lives.
Or is it because,
• Physicians are the most visible symbol of a dysfunctional health system, for it they who deliver the care, and it is they who shoulder the expenses imposed upon them?;
• the public and their to-down leaders have ignored the impossible pressures and unreasonable bureaucratic demands being placed on physicians without supplying them with the incentives and resources required to deal with those demands?
Monday, August 4, 2008
Limits of regulation - Federal Regulation of First- and Second-Hand Smoking
First-Hand Smoking
With the failure of alcohol prohibition in mind, skeptics doubt you could prohibit smoking. You might be able to regulate it by having it only sold in drug stores or by prescription. Either way, it would likely invite contraband sales and a booming underground economy dealing with cigarette sales.
In a thoughtful NEJM piece, Harvard health system history of medicine professor, Dr. Allan Brandt, says, “The regulatory status represents one of the most paradoxical stories in American medicine and public health; the single most dangerous legal product in U.S. consumer history has eluded virtually all federal regulation until now.”
He clearly believes an FDA bill now before Congress,which stresses cessation and prevention and scientific assessment of new products is a good thing. He feels trrying to reduce the prevalence and minimize damage of cigarettes through federal law is worth debating because one of five Americans still smoke, 430,000 deaths occur annually as the result of cigarette use.
Second-Hand Smoking
Illnesses related to second-hand smoking has always been debatable in some quarters. But there is a powerful movement at state, local, and federal levels to ban smoking from public gathering places, public buildings, and restaurants.
Now evidence from Scotland, which introduced legislation prohibiting smoking in all enclosed public places and workplaces after the end of March 2006, indicates the incidence of hospitalization for acute coronary syndrome dropped sharply in a ten month period after the legislation compared to the ten month before.
Overall, number of admissions dropped 17%, as compared to a 4% reduction in England, which had no legislation.
Authors of a July 31 NEJM article, from the University of Glasgow, conclude,
“The number of admissions for acute coronary syndrome degreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved non-smokers. However, fewer admissions among smokers also contributed to the overall reduction.”
A poet writing for the Scots might write,
Where there’s second-hand smoke,
There are fewer heart attacks,
That’s no joke, blokes,
Those are the facts.
References
1. A.M. Brandt, “FDA Regulation of Tobacco – Pitfalls and Possibilities,”New England Journal of Medicine, pages 445-449, July 31, 2008?
2. J.P. Pell and others, Smoke-Free Legislation and Hospitalizations for Acute Coronary Syndrome,” New England Journal of Medicine, July 31, 2008.
3. Pages 482-491, July 31, 2008.
With the failure of alcohol prohibition in mind, skeptics doubt you could prohibit smoking. You might be able to regulate it by having it only sold in drug stores or by prescription. Either way, it would likely invite contraband sales and a booming underground economy dealing with cigarette sales.
In a thoughtful NEJM piece, Harvard health system history of medicine professor, Dr. Allan Brandt, says, “The regulatory status represents one of the most paradoxical stories in American medicine and public health; the single most dangerous legal product in U.S. consumer history has eluded virtually all federal regulation until now.”
He clearly believes an FDA bill now before Congress,which stresses cessation and prevention and scientific assessment of new products is a good thing. He feels trrying to reduce the prevalence and minimize damage of cigarettes through federal law is worth debating because one of five Americans still smoke, 430,000 deaths occur annually as the result of cigarette use.
Second-Hand Smoking
Illnesses related to second-hand smoking has always been debatable in some quarters. But there is a powerful movement at state, local, and federal levels to ban smoking from public gathering places, public buildings, and restaurants.
Now evidence from Scotland, which introduced legislation prohibiting smoking in all enclosed public places and workplaces after the end of March 2006, indicates the incidence of hospitalization for acute coronary syndrome dropped sharply in a ten month period after the legislation compared to the ten month before.
Overall, number of admissions dropped 17%, as compared to a 4% reduction in England, which had no legislation.
Authors of a July 31 NEJM article, from the University of Glasgow, conclude,
“The number of admissions for acute coronary syndrome degreased after the implementation of smoke-free legislation. A total of 67% of the decrease involved non-smokers. However, fewer admissions among smokers also contributed to the overall reduction.”
A poet writing for the Scots might write,
Where there’s second-hand smoke,
There are fewer heart attacks,
That’s no joke, blokes,
Those are the facts.
References
1. A.M. Brandt, “FDA Regulation of Tobacco – Pitfalls and Possibilities,”New England Journal of Medicine, pages 445-449, July 31, 2008?
2. J.P. Pell and others, Smoke-Free Legislation and Hospitalizations for Acute Coronary Syndrome,” New England Journal of Medicine, July 31, 2008.
3. Pages 482-491, July 31, 2008.
Sunday, August 3, 2008
Quality, Physician Culture - - Health Care Poker
Health Care Poker
Poker is a card game in which players attempt to acquire a winning combination of cards that involves betting at every deal. In today’s health care reform, many consider autonomous physicians as the wild card in a deck generally stacked in favor of big government, big insurers, and big health care organizations. .
It is independent physicians, policy makers, health care executives, and reformers lament and complain, who,
• still have freedom to prescribe drugs, order tests, do procedures, and hospitalize patients, willy-nilly, as they please.
• still lack wisdom to invest in and install EMRs, refuse to abandon solo medicine, and continue to act on clinical instinct rather than on “evidence-based” protocols, perform “unnecessary” tests and operations, respond to fee-for-service incentives to do more, succumb to blandishments of device and drug manufacturers, and yield to patient pressures for the best and the latest. .
The argument seems to be: This is a free country, but quality and clinical judgments are too important to be left to independent physicians exercising their own judgment and acting on their own.
I satirized these different views in a tongue-in-cheek July 30 blog “Interview with a Health Care Buzz Word Expert.” The responses were not long in coming. Doctors greeted the blog with bemusement and amusement . Consultants were not so kind.
One consultant, Scott Hodson, formerly a Deloitte consultant who now owns his own firm to help health care organizations found my blog off point.
Here, in part, are his comments.
“Very creative and entertaining! However, I think that providers bear the brunt of the responsibility to improve the quality, efficiency and affordability of health care.
Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization/cost of care, hospitals and physicians must work together to develop a "world class" quality management foundation that includes:
Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.
Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables "real time" information.
Process: including concurrent intervention, the ability to identify key quality performance "gaps," and performance improvement tools and methodologies to effectively eliminate quality issues.
Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay "survey ready every day."
Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.
My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.”
I do not quibble with his remarks, which represent the organizational point of view. But as the August 3 “Bright Idea” section in the New York Times, notes, “small is the new big.” Health care organizations are learning the charms – and innovative side effects, - of thinking small at the physician level. . Innovations are just as likely to come from the bottom-up, physicians seeking freedom, personal satisfaction, and fulfillment, as from “progressive organization” leaders seeking control from the top down. In health care poker, physicians may hold the bottom hole card.
Poker is a card game in which players attempt to acquire a winning combination of cards that involves betting at every deal. In today’s health care reform, many consider autonomous physicians as the wild card in a deck generally stacked in favor of big government, big insurers, and big health care organizations. .
It is independent physicians, policy makers, health care executives, and reformers lament and complain, who,
• still have freedom to prescribe drugs, order tests, do procedures, and hospitalize patients, willy-nilly, as they please.
• still lack wisdom to invest in and install EMRs, refuse to abandon solo medicine, and continue to act on clinical instinct rather than on “evidence-based” protocols, perform “unnecessary” tests and operations, respond to fee-for-service incentives to do more, succumb to blandishments of device and drug manufacturers, and yield to patient pressures for the best and the latest. .
The argument seems to be: This is a free country, but quality and clinical judgments are too important to be left to independent physicians exercising their own judgment and acting on their own.
I satirized these different views in a tongue-in-cheek July 30 blog “Interview with a Health Care Buzz Word Expert.” The responses were not long in coming. Doctors greeted the blog with bemusement and amusement . Consultants were not so kind.
One consultant, Scott Hodson, formerly a Deloitte consultant who now owns his own firm to help health care organizations found my blog off point.
Here, in part, are his comments.
“Very creative and entertaining! However, I think that providers bear the brunt of the responsibility to improve the quality, efficiency and affordability of health care.
Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization/cost of care, hospitals and physicians must work together to develop a "world class" quality management foundation that includes:
Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.
Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables "real time" information.
Process: including concurrent intervention, the ability to identify key quality performance "gaps," and performance improvement tools and methodologies to effectively eliminate quality issues.
Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay "survey ready every day."
Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.
My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.”
I do not quibble with his remarks, which represent the organizational point of view. But as the August 3 “Bright Idea” section in the New York Times, notes, “small is the new big.” Health care organizations are learning the charms – and innovative side effects, - of thinking small at the physician level. . Innovations are just as likely to come from the bottom-up, physicians seeking freedom, personal satisfaction, and fulfillment, as from “progressive organization” leaders seeking control from the top down. In health care poker, physicians may hold the bottom hole card.
Saturday, August 2, 2008
Personalized Medicines
James Weintrub, a Providence, Rhode-Island, plastic surgeon and coding entrepreneur called today. He asked what I written about personalized medicine in my blog. James had seen Charlie Rose speak to Francis Collins, MD, America’s leading DNA and genome expert talk of the infinite prospects for personalized medicines, unique drugs tailored to each individual.
Nothing, I’m embarrassed to say. Genome-based medicines, or personalized medicine are the most eagerly awaited next step in the genetic revolution. The prospect of examining a person's entire genome to make individualized risk predictions and treatment decisions may soon be within reach.
It sounds logical that to have one-of-a-kind drugs tailored, customized, and targeted for each patient based on phenotypes, genetics, and environment. The excitement has grown since science completed sequencing the human genome in 2003. Many institutions are pursuing personalized drugs for each individual. Harvard and Duke, among others, are seeking just the right drug, for just the right person, at just the right time. You can find more about the quest for personalized medicines at (www.personalizedmedicinecoaltion.org)
But noble as these goals are, progress is slow.
• First, there’s scalability and sustainability. Developing drugs for individuals one-on-one is a very expensive proposition, and no one yet has come up with a feasible and affordable scheme to find the right patients and sufficient money to support the clinical trials necessary.
• Second, the results have been patchy and inconclusive so far – Herceptin for breast cancer patients whose genes express HER2 and Gleevec for patients with chronic myelogenous leukemia with certain genotypes.
It may be, of course, researchers will come up with a comprehensive broad database with magical algorithms to unlock keys to individual or cancer tissue drug responses. It may be genetic profiling will be routine in every clinical workup, and clinicians will diagnose and treat with pinpoint personalized precision, and computer stimulation can predict what personal drug to use for each individual and each cancer.
It will require cross-institutional research and massive clinical trials – both prohibitively expensive - to find why patients respond differently to the same drug. The differences may due to individual genetics for arthritis, hypertension, or high cholesterol, or to genetic variations in cancer tissues. Sorting out these differences will not be easy since each individual genome and each cancer tissue genome is made up of more than one billion genes. Because of expense and complexity, a broad breakthrough is not likely soon.
But research races are not always won by the swift, but to those plodders who work out the kinks, and sort out the drugs and the patients, one by one.
Nothing, I’m embarrassed to say. Genome-based medicines, or personalized medicine are the most eagerly awaited next step in the genetic revolution. The prospect of examining a person's entire genome to make individualized risk predictions and treatment decisions may soon be within reach.
It sounds logical that to have one-of-a-kind drugs tailored, customized, and targeted for each patient based on phenotypes, genetics, and environment. The excitement has grown since science completed sequencing the human genome in 2003. Many institutions are pursuing personalized drugs for each individual. Harvard and Duke, among others, are seeking just the right drug, for just the right person, at just the right time. You can find more about the quest for personalized medicines at (www.personalizedmedicinecoaltion.org)
But noble as these goals are, progress is slow.
• First, there’s scalability and sustainability. Developing drugs for individuals one-on-one is a very expensive proposition, and no one yet has come up with a feasible and affordable scheme to find the right patients and sufficient money to support the clinical trials necessary.
• Second, the results have been patchy and inconclusive so far – Herceptin for breast cancer patients whose genes express HER2 and Gleevec for patients with chronic myelogenous leukemia with certain genotypes.
It may be, of course, researchers will come up with a comprehensive broad database with magical algorithms to unlock keys to individual or cancer tissue drug responses. It may be genetic profiling will be routine in every clinical workup, and clinicians will diagnose and treat with pinpoint personalized precision, and computer stimulation can predict what personal drug to use for each individual and each cancer.
It will require cross-institutional research and massive clinical trials – both prohibitively expensive - to find why patients respond differently to the same drug. The differences may due to individual genetics for arthritis, hypertension, or high cholesterol, or to genetic variations in cancer tissues. Sorting out these differences will not be easy since each individual genome and each cancer tissue genome is made up of more than one billion genes. Because of expense and complexity, a broad breakthrough is not likely soon.
But research races are not always won by the swift, but to those plodders who work out the kinks, and sort out the drugs and the patients, one by one.
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