The Health Care Blog

TECH: LinuxWorld - Healthcare Day

For those of you who believe in Open Source at LinuxWorld  in San Francisco on Aug 15 there is a Healthcare Day. Sometime THCB commenter and contributor Fred Trotter is on at 2pm running a panel on innovation.

BLOGS: HEWR is up at Medical Connectivity Consulting

Health Wonk Review is up at Tim Gee’s excellent Medical Connectivity Consulting. The next HWR is going to be here at THCB on August 10 so hurry over to Dimitriy’s The Medical Blog Network to submit…

Yup I’ll remind you in advance

POLICY/HEALTH PLANS/PHARMA: Part D--a tale of two headlines

Most Beneficiaries Enrolled in Medicare Rx Benefit Satisfied With Drug Plan, Nearly Two in 10 Experienced Major Problem, Study Finds

or if you prefer

Poll shows 80% of those enrolled in Medicare drug plan satisfied

So go ahead and guess which headline came from a non-profit foundation's news service and which one was from the inhouse newsletter for the trade group for health plans, which of course run the biggest Medicare PDP (Part D plans).

So when is a series of problems not a problem? Apparently if you don’t care much about consumer problems.

34%, of seniors who have used their drug plans have experienced what they perceived as problems, including 18% who described them as "major" problems and 16% who described them as "minor" problems. The experiences cited as problems included having unexpected costs, not being able to fill a prescription at the pharmacy, not receiving an enrollment card and having to change medications because a prescription is not covered. Ninety percent of seniors who experienced minor problems and 55% who experienced major problems feel the issues were resolved satisfactorily. (my emphasis)

So by my math 9% of Part D recipients have had major unresolved problems. Most consumer companies would freak out if they had that level of unsatisfied customers.

But don’t worry, for the $600 billion over 9 years (or whatever mythical number we’re now being quoted is the cost of Part D) that the taxpayer is spending, we’re sure saving all those recipients lots of cash right? Well not quite all—in fact not even most!

Of seniors who have used their Medicare drug plans, 46% say they are saving money on prescription drug costs, while 34% say they are paying about the same as before the drug benefit and 17% say they are paying more.

Oh well, at least the people who the bill was designed to help are benefiting. On Tuesday the NY Times told us that:

The summer revival in the pharmaceutical industry continued as Merck and Schering-Plough, two major American drug makers, reported second-quarter profits yesterday that were well ahead of analysts’ expectations. Medicare Part D, which offers prescription coverage for people over 65, is fueling the profits, as drug makers benefit from new prescriptions and somewhat higher prices for medicines, Wall Street analysts say. The number of prescriptions has risen 3 percent this year, and growth accelerated in June to more than 5 percent, according to a report from Merrill Lynch. Eventually, Part D could fuel a political reaction if prices continue to rise, but analysts expect the industry’s influence in Washington will delay any changes for years.

And the taxpayer isn’t getting screwed any more than they were going to be already in Part D are they? Well there’s this little nugget too

Overall prescriptions are also increasing, according to data from Citigroup and Merrill Lynch. For the year, total prescriptions in the United States are up about 3 percent, but they accelerated in June, rising 5.4 percent over the previous June. Drug makers have also increased prices for many popular drugs and are paying rebates to the private insurers who run the Medicare Part D program that are lower than the 15 percent rebates they paid to Medicaid.

Well at least the market is working—of course Adam Smith might not notice this as being the kind of free market he was thinking about.

HEALTH PLANS: And just in case the pro-Kaiser bias is getting out of hand

Now that we've let Pat Salber be so nice to Kaiser, Gadlfy reminds me about a couple of things.

First a lost laptop apparently filched out of Oakland HQ with a mere 160,000 patients’ details on it. They were fined $200K by Dept of Managed Care for putting 150 names on the Internet, so proportionally this one should come in around the gross national product of Belgium!

And then much more dirt about the kidney transplant disaster--including the reason that the story broke. The whistleblower went to the press and the authorities including the LA Times. It was the LA Times series on Kaiser's kidney transplant program that made the brown stuff hit the whirling metal thing. And what's worse is that they still have not have had the no-holds barred public enquiry that they ought to allow and that I called for when it happened—mostly (according to Chris Rauber in the SF Business Times) apparently out of fear that it’ll upset the Permanente Group.

I half expect several commenters to (again) question how Robbie Pearl’s father really died. But the point is that the EMR KP is introducing is capable of massively improving care quality. But it’s a necessary but not sufficient condition.

Meanwhile, there are also allegations that the non-profit guys (Blue Shield and Kaiser) are joining the real schlockmeister behavior of retroactively cancelling patient policies—the ones that Wellpoint’s Blue Cross unit is in hot water for doing. No examples about KP, although there is one for Blue Shield, who’s underwriting is pretty tough these days.

So as everything in health care, there are two sides to the story. It would be very nice if KP made more of an effort to be open about this--I still think a full external inquiry into the Kidney transplant fiasco would be much better for them (and for health care as a whole) than us all having to read the tea-leaves via the unfair dismisall case....but the politics of KP as a whole are very delicate and I understand why they won't do it. I don't agree with that policy but I understand its genesis

HEALTH PLANS/PHYSICIANS/TECH:Health care, the way it should be (or How to stop worrying and learn to love the bomb), by Pat Salber

Pat Salber writes The Doctor Weighs In. She is a doc, an ex-med director at California blue shield, and a Kaiser Permanente member. And she loves them. This is why, and it’s quite an advertorial for Kaiser and an indictment of how everyone else does it. So if this becomes the standard, and people find out about it (and with $80m of advertising budget a year behind it, they will find out) can the rest of the US system compete?

Health care, the way it should be
or  (How to stop worrying and learn to love the bomb)

By PAT SALBER

I have to tell you again about what great health care I get from Kaiser Permanente Northern Cal. (Yeah, I know, they screwed up on the transplant service).  But, they are doing a lot of the things we, the wonks, have been hollering about for years.  Read this.

Sunday night I noticed new “floaters” in the right visual field of my right eye.  They were different from the run of the mill floaters – those little dark circles -- most of us have.  These were like long lines and they only moved on the right side of the visual field.  The next day, I started having sparkling lights, again in the right visual field.  Now, even an emergency physician knows this could indicate a retinal detachment (serious indeed).  So mid-afternoon, when I had convinced myself it would be stupid to miss my own diagnosis, I called KP.  The woman on the phone in the opthalmology department clearly had been trained.  When I talked about the sparkles, she put me on hold and got a nurse. 

The nurse tried her best to get me in the same day.  She had an appointment available, but being rush hour, there was no way I could make it. She carefully went over the symptoms of retinal detachment and compared them to what I was experiencing.  Together we decided it was OK to wait until the next am for an appointment.  She carefully explained that if certain symptoms occurred (e.g., a sensation of a curtain coming down over the eye), that I needed to go to the emergency department right away as that could indicate a retinal detachment.

The next day (today) I showed up at the opthalmology department.  The receipt I was given for my $15 co-pay listed the dates I had had all of my age/gender specific  preventive services and the dates the next ones were due.

There was no wait to see the doctor.  I was put in an eye exam room and saw a nurse right away.  She explained everything she was going to do.  She anesthetized my corneas,  she tested my vision (with glasses and with pinholes), she used the slit lamp to look at the corneal surface, and then she put in drops to dilate my eyes.

After about 15 minutes (waiting for the eyes to dilate), Dr. Prusiner, chief of the department came in to see me (he is the brother of Stan Prusiner, the Nobel Prize winner who discovered prions).  He did a very thorough exam of both retinas using a variety of techniques.  He explained that I had a vitreous detachment (annoying, but otherwise, no big deal).  He showed me a color picture of an eye with a vitreous detachment.  He answered all of my questions.  He did  not seem rushed (because the nurse had done a lot of the early work for him).

We were finished, he gave me a  4 x 6 piece of paper with his name, his photo and the URL of his home page.  Here’s the link  so you can see how nice it is.  This is, I think, the new KP Connect.  It also showed all of the stuff (by major categories) that he had on his home page.  He wrote down the diagnosis “vitreous detachment” on the paper and drew an arrow from it to name of the link where I would find the information he had chosen for his patients to read about this condition. He urged me to read it.  I went on the site, found the condition, and, lo and behold, everything he told me was what was on the site.

He then told me, in detail, what symptoms would require me to call or go to the ER right away.  But he assured me that the symptoms represented complications highly unlikely to occur.

By the way, he said as I was leaving.  Be sure to make an appointment with the optometrist.  I think we can improve the correction of your left eye.

I challenge you to find one single thing you would want that I didn’t get.  This is the way health care should be.

TECH: Is Continua the work of the devil

You and I might have thought that Continua was a sensible business led approach to get medical devices and remote monitoring systems operating together. But looking at this photo of Intel’s Dave Whitlinger who runs the Continua Health Alliance over at Tim Gee’s blog, maybe more sinister forces from far below are at work?

(Yes, I’m kidding)

BLOGS: New hospital industry blog

Health Care Policy, Innovation and Renewal is a pretty interesting new blog from a hopsital system strategy exec, who appears to have something of a social conscience—if that’s not a contradiction in terms! Doesn’t seem to be updated all that often but every post I read is thought provoking (wish that I could say that for THCB!). It’ll be interesting to see its development

HOSPITALS: Yet more insider trading at HCA?

Apparently the SEC is understood to be examining suspicious option trades in the run-up to the HCA leveraged buyout. Which does give me the thought, can’t Bill Frist leave well enough alone?

BLOGS: How many nurses can dance on the head of a pin?

Change of Shift, the nurses compendium is up.

 

THCB: Tech stuff

If you've tried to sign up for the THCB Update email at any point in the past two or three days you may have encountered problems. THCB's intrepid techies are working to resolve matters. Meanwhile, If you'd like to sign up, drop us an email at thcblist@gmail.com.

QUALIY/PHYSICIANS: P4P in the United Kingdom

The biggest P4P scheme in the world is going on in the UK, one that I first wrote about in early 2004. (For more on the  wider ramifications of reform in the UK ,see yet another article in this weeks NEJM) 

Note that all the GPs there have computers, so they can easily report their process behaviors. Note also that the introduction of the system as done as a way of giving extra cash to GPs, but extra cash for improving quality of primary care process. So the first year’s results are in, and the GPs have done much better than was predicted and better than most American groups studied other than the VA. I think this is so important in the light of where Medcare is going that I’m including the entire discussion section from the NEJM article from the Univ of Manchester group that studied it. It’s called “Pay-for-Performance Programs in Family Practices in the United Kingdom”, and its below the jump, as an exceprt from an article by Arnold Epstein commenting on its implications for the US

*******

In the first year of the pay-for-performance program, English family practitioners performed extremely well with respect to the quality targets, attaining a median of 96.7 percent of the available points for clinical indicators. This greatly exceeded the 75 percent predicted when the scheme was negotiated, and consequently the cost to the taxpayers was considerably more than expected. Before the new contract was implemented, family practitioners typically earned from £70,000 to £75,000 ($122,000 to $131,000). The pay-for-performance program increased the gross income of the average family practitioner by £23,000 ($40,200), although the practitioners bore any additional nursing and administrative costs of meeting the targets. In 2005–2006, family-practitioner income will rise even more, since quality payments have been increased to £125 ($218) per point.

Exact comparisons with U.S. data on quality of care are difficult because of differences in indicators, dates of data collection, and samples. However, some limited comparisons are possible. For example, 91 percent of patients with diabetes had their glycated hemoglobin levels measured in 2004–2005 under the new pay-for-performance program in England. In comparison, glycated hemoglobin levels were measured in 94 percent of patients with diabetes treated by the U.S. Department of Veterans Affairs in 1999–2000 and 93 percent of such patients in 2000–2002,20 in 83 percent of patients with diabetes treated by commercial managed care groups in the United States in 2000–2002, in 82 percent of patients with diabetes treated by Pacific Northwest physician groups with pay-for-performance programs in 2001–2002, in 64 percent of patients with diabetes treated by California physician groups with pay-for-performance programs in 2002–2003, in 89 percent of Medicare patients with diabetes in 2004, and in 76 percent of Medicaid patients with diabetes in 2004. For other aspects of diabetes care, including blood lipid testing, eye examinations, microalbuminuria screening, and influenza vaccination, performance in the first year of the new contract also placed family practitioners in England on a par with their better-performing U.S. peers.

There is no baseline with which to compare performance in the first year of the U.K. program, although the quality of care was already improving before its introduction. The high levels of achievement might suggest that the targets were too easy to achieve. The scheme has been revised for 2006–2007: all minimum and some maximum payment thresholds have been raised, 30 indicators have been dropped or modified, and 18 new indicators have been introduced.24 The high achievement levels might also have resulted from misreporting by practices. To counter misreporting, Primary Care Trusts, statutory bodies responsible for the delivery of health care in local areas, inspect all local practices and undertake detailed audits of randomly selected practices and those suspected of incorrect or fraudulent returns. The results of these audits are not, however, publicly available.

Because achievement was universally high, there was little variation between practices. It was not surprising, therefore, that socioeconomic and demographic factors, which profoundly affect population health and the use of health care facilities, had relatively little influence on achievement. Although practices that served lower-income populations had worse overall population achievement, the effect was small, and they were no more likely to use exception reporting to exclude patients than were practices with more affluent populations. Deprivation-related health inequalities therefore appear unlikely to have been greatly increased by the introduction of the financial incentive program. Smaller practices performed marginally better overall than large ones, although there was much greater variation in the performance of small practices, and many smaller practices are believed to have merged in the face of the administrative pressures from the new contract.

Imputation of rates of exception reporting was possible for only 30 of the clinical indicators (39 percent), and we cannot determine how representative these indicators were. There was a significant positive relationship between rates of exception reporting and reported achievement for these indicators, but the effect was small. It is possible that practices that were better at identifying and treating patients with chronic conditions also tended to identify more patients for whom the targets were inappropriate. Alternatively, practices may have "gamed" the new system. The generally low levels of exception reporting suggest that large-scale gaming was uncommon. However, a small minority of practices exception-reported a much larger proportion of their patients: 91 (1.1 percent) excluded over 15 percent of their patients. These practices warrant closer examination to determine whether their use of exception reporting was appropriate.

The rate of exception reporting varied considerably according to disease group. There were very low levels of exception reporting for hypothyroidism and relatively high levels for mental health problems, coronary heart disease, and chronic obstructive pulmonary disease. This variation may reflect the nature of the indicators for each disease. For example, to meet the main hypothyroidism target, practices were required to record that a patient's thyroid functions had been checked in the previous 15 months. This was a relatively easy target to meet; hence the achievement level was high and there was little reason to exclude these patients. Since the indicator carried only a modest financial reward of 6 points (£456, or $800), there was also little incentive to game. In comparison, the main mental health indicator required a review of medication, physical health, and coordination arrangements with secondary care for patients with severe long-term mental health problems. Not only would one expect legitimate exception reporting to be higher for this indicator, but the incentive to game would also be greater, since the indicator was worth 23 points (£1,748 or $3,050).

Several lessons can be drawn from the U.K. experience. First, the U.K. program was costly and was funded with substantial additional monies rather than by restructuring existing payment systems. In addition to the payments for achieving quality targets, there were further costs, to both the practitioners and the government, of developing and implementing the information-technology systems required to monitor the program. Budget-neutral programs would face greater resistance from family practitioners. Second, a clear baseline is needed to avoid paying for improvements that have already occurred. Third, geographically staggered introduction would enable policymakers to better estimate the quality effects of the program. Fourth, introducing pay-for-performance incrementally reduces risks for providers and payers. Fifth, payers should allow for the possibility of higher-than-expected achievement. Sixth, the risk of inappropriate treatment can be decreased with the use of mechanisms such as exception reporting, but monitoring is required to prevent abuse.

The U.K. experience suggests that greater changes in professional practice can be achieved through pay-for-performance programs than previous research indicates. We do not know whether the size of the financial incentives made the difference in the United Kingdom, and if so, how big incentives need to be. Whatever the case, financial incentives should be aligned to physicians' professional values to avoid serious distortions of care.

All of which leads commente Arnold Epstein to believe that it's going to happen here too soon with CMS leading the way on doctor pay. But there are big differences

In contrast with the British system, we can expect the CMS's approach to extend beyond primary care physicians. In this country, specialists, including surgeons, receive a substantial majority of payments for physician services from the CMS. Because the CMS is unlikely to restrict its efforts to generalist physicians, we must develop a broader array of quality measures for specialists' care to make this policy effective. 

We can also expect the continuing budget deficit to constrain the magnitude of payments. In the United Kingdom, pay for performance was adopted coincident with a substantial increase in funds provided to the National Health Service for payments to physicians. Thus, most physicians benefited from the new system, and no physicians saw their incomes decrease. In the United States, however, budgetary pressure will undoubtedly force the CMS to establish more modest initial financial incentives, probably on the order of 1 to 2 percent of payments to physicians — substantially less than the 5 to 10 percent often provided by health plans to provide sufficient impetus for doctors to change their practices. Of course, the British numbers are larger still — averaging approximately 30 percent before physicians paid any extra nursing or administrative costs. If larger incentives are needed, financial pressures to introduce budget-neutral policies will probably force the CMS to carve out quality bonuses from funds available for annual increases in payments or even from funds for existing payment levels, making some physicians winners and some substantial losers.

Then of course there's the teeny tiny issue of whether with no more money this has a chance of not being torpoeded by the AMA and their ilk. We'll see.

But this is clearly the biggest battle inside health care for the next few years.

HEALTH PLANS: You sleep with scumbags, you expect to catch nasty diseases

More on the incredible United Healthcare/Golden Rule story that Joe Paduda’s been following. Joe’s latest is called Who is UHC's customer?

Essentially United’ high deductible subsidiary Golden Rule is advertising that it’s selling a HDHP with agreed procedure rates for customers—just like the vast majority of PPOs out there. But when the time comes, they are contractually allowing their providers to balance bill the customer over and above the rates they’ve agreed. The real kicker is that are keeping that fact secret from their customers because—absolutely incredibly—they claim it’s a trade secret between plan and provider. So they tell the customer that they’re buying into a network with pre-negotiated rates, but it’s not true. This is pretty much straight fraud.

Sadly, Golden Rule has been a scumbag organization since day 1. It was started by Patrick “looney” Rooney and its goal has been to change the law so that it can sell more of its highly underwritten, high margin HDHP policies. After numerous contributions to certain Republicans, who lets face it couldn’t give a rat’s arse about the poor consumer despite all their high fallutin rhetoric about 21st century health care, the HSA is now the law of the land and plans like Golden Rule (as well as one hopes somewhat more ethical ones) are very hot.

So hot that managed care companies decided (as I’ve said before) that acquisition rather than imitation is the sincerest form of flattery.  UnitedHealth Corporation bought Golden Rule for $500m in 2003 when the HSA law was passed. Rooney meanwhile moved onto better things like buying basically reverse racist anti-Kerry commercials on black radio stations in the run-up to the 2004 election.

In a Businessweek article last year United said that it had cleaned up Golden Rule’s scummier practices: 

Soaring demand is one reason why UnitedHealth paid $500 million in 2003 for Golden Rule, of Lawrenceville, Ill., problems and all. Since 1995, Golden Rule has faced 15 investigations by insurance officials for aggressive sales tactics and questionable marketing. That compares with just nine investigations at UnitedHealth, though Golden Rule's revenues barely equaled 3% of UnitedHealth's 2003 revenues. At its low point, in 2002, Golden Rule settled for $660,000 a nine-state investigation that found its small-group policies required employees to submit "proof of good health," a violation of federal health-care rules. In addition to the payment, Golden Rule agreed to make "substantive" changes in the way it does business in those states.

Since taking over Golden Rule, UnitedHealth has made further strides. Complaints against the outfit have dropped by more than half. And as UnitedHealth expands Golden Rule, it is encouraging consumers to check health-care costs via its online "treatment cost estimator" so they aren't surprised by big out-of-pocket bills. "When we acquire a company, we take responsibility for all their past conduct," says Mark F. Lindsay, UnitedHealth's vice-president for communications and strategy.

Apparently you have to now actually have the double secret “treatment cost estimator” which tells you what your balance billing exposure is on top of the secret negotiated rate

All of which goes to show that you can take these trash plans out of the trailer park — into the big respectable corporation — but you can’t take the trailer park trash out of the plan. (With apologies to THCB readers who live in trailers). And of course the problems they bring with them may just spread over to the rest of the organization—which since 2004 seems to be back-sliding on its “be nice to providers” mantra with nasty little episodes in Arizona and New York.

Then again given the charges filed against Brocade’s CEO for backdating stock options and the virtual certainty that after their screwing around with the dating of option awards they are next on the SEC/DOJ hit list, it may just be that instead of sorting out this mess United’s senior management has got, ahem, other things on its mind.

TECH/QUALITY/PHYSICIANS: Healthcare and The Long Tail - Searching for help when you’re on the wrong-end of the curve by Jim Walker

Two things have got my attention recently. The first is the concept of the long tail in medicine, which I've thought about alot since my fiancee got an odd condition (shortness of breath) that didn’t match any of the symptoms the text books said were the symptoms of the usual shortness of breath. She endured several doctors diagnoses of diseases that went from the wrong to the ridiculous (panic attacks that lasted for weeks?). After much, much digging around on the web she found a patient testimonial from someone who had long term shortness of breath and related it to caffeine. Yup, drinking coffee was causing the problem. But because it was a rare symptom of what's not normally a medical problem she had to go through the annoyance (and worry) of being wrongly diagnosed and put on drugs she didn't need, and now she can’t drink coffee or eat chocolate—her life  must barely be worth living!

The second is a plethora of people writing to me telling me about XYZ product that is the greatest since sliced bread and would I please praise it on THCB. One such person is Jim Walker from new physician social networking site MyMedwork. Usually when I request that said person writes a piece putting their service in context I get self-serving marketing jargon, and when I request that they instead really write a general interest piece I never hear from them again. In contrast Jim wrote an excellent explanation of the Long Tail in health care. Here it is:

Healthcare and The Long Tail

By JIM WALKER

My neighbor brought her son to the doctor this summer for a rash that wouldn’t go away. “The doctor had never seen anything like it,” she explained.  “In fact, he brought in the other doctors to take a look at it, and none of them had ever seen it either.”  Now I don’t know about you, but listening to her reminded me of my worst medical nightmare of things I don’t ever want to hear from my doctor:  “Excuse me, do you mind if I bring in some of the residents? We’ve never seen a case like yours before.”

In a recent THCB post, author Maggie Mahar writes that “Ambiguity haunts medical care”. She goes on to quote Dr. Atul Gawand – “Uncertainty is the core predicament of medicine . . . the thing that makes being a patient so wrenching, being a doctor so difficult and being part of a society that pays the bills so wrenching."

 

It’s important to note that for a great many cases, ambiguity is not really an issue.  This is because the distribution of medical ailments follows a curve very similar to Chris Anderson’s “Long Tail”, with a great many common “blockbuster” ailments stacked up high on the left-hand side of the curve. For those not familiar with the Long Tail, Anderson describes how Amazon, Netflix, and other online retailers sell lots of the usual blockbusters, but actually derive more total volume from 100s of thousands of niche products.  In healthcare, it is the left side of this distribution curve which inspires (for better or worse) Wal-Mart, Target, and others to offer “Doc In A Box” services - Allergies, Bladder Infections, Bronchitis, Ear Infections, Pink Eye, Sinus Infections, and a full battery of vaccines – all served up for a fixed price while you wait.

 

On the right hand end of the curve though, the NIH Office of Rare Disease classifies over 6,000 conditions, each afflicting fewer than 200,000 Americans.  Along this part of the curve, things do indeed get very ambiguous in a hurry – both for patients and physicians. Specialization is a response to this range of ailments (“nichefication” in Anderson’s terms), and brings physicians repeated cases of a particular nature – giving them the confidence that they can routinely diagnose and treat a high percentage of these patients. However, even within a particular specialty area, cases will naturally follow a distribution curve from typical to atypical. Unto themselves – atypical cases are just that – one of a kind aberrations that force physicians to go outside their typical “comfort zone” of diagnosis and treatment.  For each individual physician, these atypical cases feel like the exception rather than the rule. What the Long Tail suggests though, is that taken in their entirety, these rare cases actually compromise a large percentage of all medical cases. In fact, over 25 million Americans suffer from a “rare” condition.

 

This is problematic, because in general, physicians – and the healthcare system as a whole - are not well prepared for dealing with the many and inevitable rare cases. In fact, statistics show that the median time to diagnosis of a rare condition is six months, and the average is almost three years! When faced with an atypical case, most physicians will begin to consult the literature, and/or confer with their colleagues. Ironically, it is at this moment that the Long Tail shows up again in a quite surprising and often detrimental fashion. This is because recent studies in social and information analysis reveal that our network of professional contacts and information sources follows the same type of distribution curve. In other words - we all generally tend to connect with the same 15 or 20 trusted colleagues on a regular basis, and we all gather our information from a limited stream of trusted sources. Beyond this trusted core lies an entire world of other people and sources we rarely connect with, if at all – our own social and information “long tail”. Generally, using a network of trusted sources (while tuning out most everything else) is actually very efficient at handling a majority of our day to day needs. For the atypical situation though, just when we really need to break out of our habitual way of doing things - our trusted sources generally don’t deliver. They’ve all been drinking from the same information punch bowl.

 

So, we have to head out to the right-hand side of the curve – and begin finding and evaluating people and sources we don’t really know. For a student or researcher, this type of research can become a time consuming, challenging, but often rewarding journey. But, for a patient and physician confronted with a puzzling and life threatening illness, the stakes are much higher and time is at a premium. In today’s system, the physician often must address this dilemma by referring the patient to some other specialist – with the hope that maybe they will have the knowledge or connections to form a proper diagnosis and treatment protocol in a timely manner. The patient of course, must continue to move from specialist to specialist, their rare case still in hand.

 

Not surprisingly, the Internet has proved both boon and bane in this situation. Patients and their families are using the Web to dig into the latest medical research. However, matching a worried patient or family member against 1,706,532 Google results is usually a prescription for both confusion and high blood pressure.

 

On a more encouraging note, patients stuck along the right-side of the curve with a “niche disease” are using the extraordinary reach of the Web to discover that they are not so atypical after all. It’s probably no surprise to THCB readers that patients are banding together around wikis, chat rooms, blogs and social networks to offer each other information, empathy, and inspiration. (This is not so different in network theory terms from when fans of a niche band find each other on MySpace). Some of these disease state patient networks are sponsored by  pharma marketing, while others are grass-roots efforts, usually led by  a parent or family member related to one of the patients.

 

Physicians are also turning online in large numbers. Manhattan Research reports that more than 600,000 physicians are using search engines to find medical information. Are they searching about how to treat their day-to-day typical cases? Very unlikely. Chances are, they are researching an atypical case. However, if two physicians search – for example, on “phylloides tumors” at Google they each receive the same list – but have no easy context by which to evaluate the 13,600 + search results! 

 

Social network software may be one way to help physicians overcome this “search result overload”, allowing them to move faster and more confidently outside their circle of trusted sources and down the long tail, especially when faced with a “rare” condition (which as we’ve noted – is not such a rare occurrence in the aggregate). For example, within MyMedwork , search priorities start with the individual physician’s network of trusted colleagues and work outward from there. In other words - each physician gets a totally unique list of search results based on who in their own extended network is likely to possess useful information. Because the medical community is so small, it turns out that physicians are usually quite closely linked to any given article or study, they are just not aware of the connection. By viewing the social network connection within their search results – they are then in a position to more accurately judge the quality of the information – either by checking with the in-between link (i.e. “Hi Dr. Jones, I notice you’re connected to Dr. Watson – what do you think of his study on phylloides tumors?”) – or by contacting the physician directly (i.e. “Hi Dr. Watson, I see you went to medical school with my colleague Dr. Jones, do you mind if I ask you a few questions about your study?).

 

The implications of The Long Tail and social network analysis for healthcare are just beginning to be explored and understood. It is already clear though, that as the entire healthcare field continues to undergo dramatic change, and “atypical” rare disease states become ever more typical, ambiguity and uncertainty will continue to impact medical decision making. In this environment, the need to develop richer and more varied sources of information, and the value of far-reaching, online social trust networks will become increasingly apparent for patients and healthcare practitioners alike.

YOU'VE GOT MAIL

Or we've got mail. Or we've all got mail. Or something ... 

After much late night heroism by THCB's trusty (and highly sensitive) tech staff, the THCB email list is up and running. If you'd like to get a quick email in your inbox with a rundown of new posts - with news flashes for important stories - you can sign up here.

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PBMs: Rebates are nearly dead; can the PBMs keep their generic margins?

Vanessa Furhman continues her swath through the PBM industry in the WSJ. The article is called Managers of Drug Benefits Agree To More Transparency in Pricing. Apparently bullied into this by fear of losing some big clients, both Medco and Caremark are going to disclose their prescription pricing.

Responding to pressure from some of their biggest corporate clients, two big pharmacy benefit managers agreed to provide more information to employers about the way they price and administer employee drug purchases. The two PBMs, Medco Health Solutions Inc. and Caremark Rx Inc., each handles the drug benefits for tens of millions of Americans. They have agreed to participate with eight smaller PBMs in a purchasing model that would require them to pass on to clients their own costs for acquiring retail and mail-order prescriptions. They also have agreed to pass along the price rebates, rarely disclosed in the past, that they receive from drug manufacturers.

Well actually Medco was making its total rebates clear and has begun passing back to its clients a significant chunk of its rebates last year, but its profits increased anyway because it made it up on the spread on mail-order generics. So will they start disclosing what they pay for those versus what they charge? Unclear:

Medco and Caremark both started the coalition's process to become certified when it launched last year, but dropped out along the way. A big sticking point for them, according to some people working with the coalition, was the demand for full transparency and acquisition-cost pricing on generics ordered through the mail. PBMs enjoy some of their steepest markups and profits on mail-order generic drugs.

It’s not evident that they will be doing this, although smarter employers can find out market generic prices, see what they’re paying and figure out the difference. Something not many have bothered to do--to their great cost.

But if they succeed in beating the PBMs up on rebates and on generic spreads, the enormous profitability of the PBMs (Yup, it is enormous—around 50%  net margins if you don't look at the cost of the drugs which are mostly a pass thru) can’t continue. So does Wall Street believe the end is nigh?

Judging by the change in their stock price, not exactly.

 

THCB CLASSIFIEDS

INFORMATION THERAPY (Ix) is transforming health care. Join us in Park City UT for the Fifth Annual Ix Conference, "Catalysts for Innovation"Sept 25-27, 2006.  To register or for agenda details go to:
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DISEASE MANAGEMENT BOSTON At a three day conference in Boston MA, scheduled between July 31 and Aug 2, industry leaders from managed care companies, employer groups purchasing healthcare services, providers, third party administrators, physicians, healthcare technology players, nursing and pharmacy practitioners, disease management experts will meet at the 4th Annual Disease Management Conference. The event is posted online at www.srinstitute.com/ch142. 

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TECH/HEALTH PLANS: JSK on Health IT After the Employer-Sponsored Health Era

JSK is up on iHealthbeat about Health IT After the Employer-Sponsored Health Era. 

Go read.

HOSPITALS: Dr. Anna Pou Defense Fund

From THCB's New York Desk ... A defense fund has been set up to help cover legal expenses for Dr. Anna Pou and the two nurses charged with murder by Louisiana attorney general Charles Foti in the Memorial Medical Center case last week. Contributions should be mailed to:

Dr. Daniel Nuss, MD
Professor and Chairman
LSU Dept. Of Otolaryngology
533 Bolivar St, 5th Floor ENT Suite
New Orleans, LA 70112

HOSPITALS: The secret to Sutter's high margins?

Appears to be defamation suits! Yup Sutter just got awarded $17.3m because

Unite Here, one of the nation's largest unions that represents hotel, restaurant and laundry workers, defamed Sutter Health early last year by sending postcards to women of child-bearing age in Northern California claiming the organization's hospitals used unclean linens. The union was in a labor dispute with the laundry service that cleaned the linens at the time.

Of course the cynics amongst us might just wonder if Sutter’s continued combination of being the region’s highest cost provider and its most unpopular employer are in any way connected—and whether that really does indicate that Sutter’s only concern is to “enhance the health and wellbeing of people in the communities in which we serve through a not-for-profit commitment to compassion and excellence in health care services”. (Yes, that is their mission statement), especially when Sutter is happy to go to the mattresses to protect its way of doing business, despite in some cases the significant opposition of those communities to its unwillingness to get to a compromise. Still as they say that’s showbusiness, or whatever passes for it in the hardball world of American health care.

POLICY/INTERNATIONAL: Canadians somewhat grumpy about waiting, but not waiting that long

How bad are those terrible waiting lists in Canada? Well if you hang with the loonies at Fraser and PRI they average 10 months for a typical pregnancy and care for everyone else is delivered only by morticians. On the other hand, StatCanada (the official government body, and this one I believe is an independent bunch of civil servants rather than the US variety who’s reports are re-written by 23 yr old Republican staffers) is out with some real data.

What’s the conclusion? Canadians have to wait a little bit, and they’re pissed off, but only a little bit

Results for 2005 indicate that waiting for care remains the number one barrier for those having difficulties accessing care. Median waiting times for all specialized services have remained relatively stable between 2003 and 2005 at 3 to 4 weeks, depending on the type of care. There were some differences noted in selected provinces. Most individuals continue to report that they received care within 3 months.

Similarly, patients’ views about waiting for care have remained  fairly stable between 2003 and 2005. While 70 to 80 percent indicated that their waiting time was acceptable – there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care.

And how bad did that wait make them feel? Well most didn’t seem to worry at all but some were pissed off.

The proportion of patients who felt that their waiting time was unacceptable was highest among those who waited for specialist visits (29%) and diagnostic tests (21%) and lowest among those who waited for non-emergency surgery (16%) (Chart 2 ; Table 9) even though individuals are more likely to wait longer (i.e. > 3 months) for non-emergency surgical care compared with other specialized services (Table 7).

And for some the wait involved real inconvenience and pain. But that was less than 20%.

Approximately 18% of individuals who visited a specialist indicated that waiting for the visit affected their life compared with 11% and 12% for non-emergency surgery and diagnostic tests respectively. (Table 10)

And most of that was stress related rather than actual pain, although there was some of that too with about half experiencing pain. (These are proportions of those who experienced adverse effects from waiting)

Most of those who were affected reported that they experienced worry, stress and anxiety during the waiting period: ranging from 49% among those whose lives were affected by waiting for non-emergency surgery to 71% among those affected by waiting for a diagnostic test. (Table 11) Between 38% and 51% of individuals waiting for specialist services experienced pain and close to 36% of those who were affected by waiting for non-emergency surgery indicated that they experienced difficulties with activities of daily living. Approximately 28% of those who were affected by waiting for a diagnostic test indicated that it resulted in worry, stress and anxiety for their friends and family.

But of course what this doesn’t tell you and what the myopic Canada bashers like Gratzer, the PRI crowd and the AMA guy all fail to point out is the other half of the equation.

Even if every single American never had to wait for any care, there is considerable the impact because of our system on the financial health of poorer Americans, and there is also consequent impact on those poorer Americans’ access to care services. Below is a chart from the 2004 Health Affairs report which shows that on a raft of issues, like not getting care from a doctor, skipping recommended care, and not filing prescriptions, the direct cost of care here impacts people just as much, if not more so. And of course some substantial number of Americans (whichever side of that argument you believe) are going bankrupt because of it.

Yes there are problems with the Canadian system. Yes there’s room for honest debate about it.

But take the veil of ignorance test John Tierney uses in his columns in the NY Times. If you didn’t know you were going to be born or become rich, which system would you rather be in given the realistic chance that you might end up poor? The one that will get to you if you’re prepared to wait a few months, or the one that you won’t ever get to because you can’t afford to, and that might bankrupt you if you really need it? I bet you nearly half Americans would change places if they knew.

TECH: Cerner stock heading up again?

Following almost a 30% fall from its heights late last year, Cerner’s stock seems to be on the move again. Its numbers had lower profits than the analysts guessed but higher revenue, and then they raised guidance for profits and revenue for Q3. After so many months of bad news the stock was up over 14% on Friday. It’s still 20% of its all time high, but the UK may start delivering (as in cash—as no one there’s got paid yet) and sales in the US still seem to be chunking away. Perhaps the people who piled in today know something?

HEALTH PLANS/POLICY: eHealthinsurance still skipping stats 101

eHealthinsurance is out with its annual report of what premiums are in different cities and they’re still comparing the price of rotten month old apples with sweet juicy, juicy mangoes. And amazingly enough they’re different. Basically some states ban underwriting and therefore have insurance which is more expensive. So what I said last year when they said that prices were going down still applies—

On further review there are more questions than answers. Who got insurance? Was this group more underwritten (i.e. healthier) than the previous year? And what benefits were they getting compared to last year?  And were there changes in deductibles, co-pays and out of pocket maximums?

Just saying that the premium went down is a bit like saying the average price of a BMW 3 series is less this year on average because more people are buying them without the fully loaded options. And if it's really true that apples for apples the premiums went down why didn't eHealthinsurance.com put that information in the report?

Although last year apparently “prices went down” and this year they didn’t say that, so it’s pretty damn likely that if you compared apples to apples of the stripped-down underwritten plans they’re looking at, prices went up.

Of course in practical terms this report is useless. I’m a great example in that I applied for two identical policies from different carriers on eHealthinsurance—both quotes about $100 a month for a $2500 deductible plan. But when the underwriting was done, one was still $100 a month and the other wouldn’t take me at all and suggested I went in the guaranteed issue pool at $400 a month for a $4000 deductible. So quoting price without knowing what the individuals concerned need to go through to get the insurance and therefore knowing the actual price is useless.

I do note one little thing in their report. They say that St Louis Missouri has the cheapest children's insurance premiums ($29 a month) and yet there are 119,000 uninsured kids in Missouri. In other words very cheap—or even free given the numbers who don’t sign up for the SCHIP programs—isn’t cheap enough to get kids (and adults) insured. eHealthinsurance seems to be surprised about this.

The only logical conclusion is that health insurance needs to be compulsory and automatic (although not of course free to those who can afford it). And in fact even eHealthinsurance could do OK in such a system, although the logical ramifications of it would be horrendous for many of the plans they broker for.

TECH: Why we love HISTalk

Every so often Mr HIStalk reminds me why he’s the best blogger in Healthcare IT and possibly far beyond:

Kaiser Permanente's Northwest region president resigns, seemingly because of computer problems that hurt earnings. "Kaiser launched a computer system to govern billing for its high-deductible health plan and for Medicare enrollees, but halted billing for both products in June 2005 due to a technical glitch." If you had all the money that various tentacles of Kaiser have spent on botched IT projects, you could be up there on the dais with Bill Gates and Warren Buffett, giving it away to the less fortunate, which would be just about everyone.

QUALITY/CONSUMERS: A really personal piece about obesity

From Pat Salber at The Doctor Weighs In, here's a very personal look at the life of someone extremely obese as a side effect of diabetes . Well worth reading, even if it might spoil your appetite and get you to check up on your blood sugar levels.

TECH/POLICY: All Oprah's fault

You just thought she just plugged crappy books. But no, apparently the medical arms race is all Oprah's fault!

TECH: IOM reccomends ePrescribing by 2010

The IOM is out with another report on medication errors in which it recommends the use of ePrescribing for all scripts by 2010. And it’s made it into the news, at least into the AP Headlines where the tale is told that drug errors hurt 1.5 million.

Perhaps someone should let whoever took the ePrescribing mandate out of the final language in the MMA in 2003 (after it made it through in the House version of the bill) know that they’re killing people and costing payers a fortune. But then again I wouldn’t want to point fingers at anyone in particular.

 

POLICY/HOSPITALS: Joe agrees that end of life care costs too much

You don’t need me to prattle on about the systemic over-spending on end of life care when Joe Paduda is doing it instead. But on the day when we’re arresting doctors for delivering what they perceive to be the best care at the end of life, albeit in extreme circumstances, it is about time that someone started taking it seriously.

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TECH: PHR has opportunity to go mainstream

Wellpoint is going to roll out the WebMD PHR based system which has been working at Empire Blues (Wellchoice) for about a year to the rest of its plans to the rest of its plans. So theoretically up to 34 million people will have access to a PHR. I wrote about the WebMD solution before, so I won’t go into it much, but there are two quick points beyond the fact that (at last!) PHRs have the opportunity to go mainstream.

1) This is a vindication of the ASP model—these records live on WebMD's servers rather than on Wellpoint’s. I never thought that the big insurers would allow another company to take their consumers’ data for fear that they would also take their consumers as well. That was certainly a concern of the plans that we were trying to sell PHRs to at i-Beacon which was why we sold enterprise software rather than an ASP service. WellMed (the company who’s PHR is the core of WebMD’s current service) was always an ASP model. And the answer is, the lowered costs of the ASP model outweigh the fear that WebMD will make it easy for another plan to assume the members data. One WebMD insider told me that they will be introducing a way to move data between plans. So the member will find “data lock” is NOT a reason to avoid moving plans, and technically they may not even have to take it off the server, assuming that WebMD is the back end for both plans. And of course potentially WebMD can start offering other health plan services and even start competing with its clients. But that’s another story.

2) Just as the private sector starts to sort this out with providers using Epic’s MyHealth to give access to the records, and WebMD starting to make real strides, CMS is starting experimentation, and Foundations are getting into the mix too with grants to help figure out what applications are needed. Are they not a bit late to the party?

And finally—it’s about bloody time!!

DISEASE MANAGEMENT BOSTON JULY 30 - AUG 2
At a three day conference in Boston MA, scheduled between July 31 and Aug 2, industry leaders from managed care companies, employer groups purchasing healthcare services, providers, third party administrators, physicians, healthcare technology players, nursing and pharmacy practitioners, disease management experts will meet at the 4th Annual Disease Management Conference. The event is posted online at www.srinstitute.com/ch142.  Learn about advertising on THCB.
 

QUALITY/PHYSICIANS: Just what we need now, another grandstanding politician on end of life issues

I’ve been having a backchat email with the people from the Tenet Shareholders Committee. They are enjoying the legal  attack on the Louisiana physician who is supposed to have performed a mercy killing or provided ample pain medication at Tenet’s Memorial Hospital a little too much for my taste. Admittedly they are so opposed to Tenet that this one is too easy for them. But I doubt this one has anything to do with Tenet, which frankly didn’t do much to help its patients (HCA was a little more honorable).

But where the hell was the Louisiana or New Orleans AG (or for that matter any other level of government) when desperate physicians, nurses and patients needed help? Absolutely effing nowhere. A humane person wouldn’t leave a dog to slowly die or drown in the 105 degree heat, let alone another human. And it seems to me that in absolutely desperate circumstances, Dr Anna Pou did what she felt was best for those patients.Yet six months later a grandstanding DA gets his jollies off by sending physicians and nurses on trial for homicide.

This is total bullshit. A series of studies in the 1990s showed that physicians routinely ignored DNR orders. I don’t recall any of them being prosecuted, but they probably caused more harm and inflicted way more distress on patients than Dr. Pou would have done under any normal circumstances…..and let us not forget—those were anything but normal circumstances. If I was a patient there suffering with no water, no power,and no hope other than suffering a long agonizing death—I’d have been very grateful for the relief Dr. Pou’s care would have given me in my final hours.

And now we’re going to send her to jail?!

 

QUALITY/HOSPITALS: I shouldn't joke about this, but...

....you've got to ask if this is is a case of a fatal nosocomial illness.

TECH: Tim keeping track of healthcare unbound

Over at Medical Connectivity Consulting Tim Gee is blogging up a storm about the Healthcare Unbound conference going on in Boston. For those of you who don't know “Healthcare Unbound” is our friends at Forrester’s cute-sy way of talking about remote monitoring, but they’re good guys so let’s let them have their phrase and their fun!

 

POLITICS/POLICY/HEALTH PLANS: On the Blues' political giving & CDHP complexity

Says here that Blues Plans Favor Republicans With Their 2006 Campaign Contributions. But I think what it means is that they’re favoring incumbents. Having said that and reading the polls and the tea leaves, I think the Blues might think about evening up those contributions given that the Congress is as likely to flip over his year as any since 1994, and that the Blue Dog Democrats are the crowd most traditionally aligned with their interests.

Meanwhile, Joe Paduda is showing that the CDHP is even more confusing to consumers than ordinary health plans. Well, when United bought the shysters at Golden Rule, you didn’t actually think that they were going to reform them, did you?

 

POLICY/THE INDUSTRY: Nice work if you can get it

So for rewriting Alain Enthoven’s lectures from the late 1980s and missing the main points, apparently Michael Porter is being paid $50,000 a day, and that is a discount from his apparently usual fee of $100,000! Damn, that’s nice work and yes I am very jealous. Hopefully I’ll soon have his co-author Elizabeth Teisberg on THCB to explain what I don’t understand about their book which I’m chunking through at the moment.

When I said he was sinking in the health care quagmire, I should have said that he would be rolling in it.

PHYSICIANS/INDUSTRY: Retail clinics

I recently met Michael Howe who is CEO of MinuteClinic, and he had the good graces to call me back and talk on the day that they sold out to CVS. Very classy as it would have been easy to blow me off.

So the rumor quoted here is that CVS paid $170m for the company—certainly an endorsement that they at least think that retail NP clinics are real. But if you want to really know more, look at this new report on retail clinics from the California Health Care Foundation written by Mary Kaye Scott. Very nice summary indeed.

PHARMA/CONSUMERS: Med Solutions

This is more of a public service announcement, but Med Solutions offers a service which can put you in touch with all the patient assistance programs from big Pharma. It looks to be well worth checking out if you need drugs and can't afford them.

BLOGS: Medpundit's back

My fiancee complains when I come to bed late after blogging. Medpundit’s family complained when she ranted to them instead of to us. So she’s back! Hi Syd and welcome back!

HOSPITALS/POLICY: Unhealthy & unhappy Returns from BillMon

I missed this but last week my favorite writer on the entire Internet, Billmon at the Whiskey Bar, wrote about health care. 99% of his posts are about foreign policy, from an extremely cynical point of view. But this time he looked at the capital problems facing hospitals and his extrapolating guess is that to maintain the profitability of hospitals we will soon be allowing emergency rooms to turf people out to die in the streets. His piece on the future of EMTALA (not that he uses the term, but he clearly understands it) is called Unhealthy Returns.

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PHARMA/POLICY: Medicaid gets screwed over on best price, Ignagni fibbing again.

A little while ago I sat through a webcast starring my favorite factually challenged health plan lobbyist. Karen Ignagni said this about the costs of pharmaceuticals for Medicaid that are now bought instead by the private plans working under Part D:

"I'm hearing shock from (state) Medicaid directors that we're getting better prices than they are"

At the time I postulated this

Ignagni is either lying here (or massively overstating the truth from a few anecdotes), or going to find a few men in sharp suits from the rich part of K street funded by big Pharma coming down to see her carrying baseball bats.

You see, Medicaid plans get from pharma manufacturers what’s known as “best price”. In other words if they give a better price to another customer, they also have to give that price to Medicaid. Medicaid is still of course buying its drugs for its non-Medicare dual eligible population. The drug companies know this, so I doubt that what she’s saying is true. But if it is true that Ignagni’s health plan members are getting a better price than the states are, then the states can go back to the pharma manufacturers to get a better rebate — oh, and also prosecute Pharma companies for fraud over not giving them best price, as has happened many times.

And today writing in the New York Times Milt Freudenheim has picked on the issue, which he calls  a Windfall From Shifts to Medicare. So was Ignagni telling the truth? Were the prices that Medicaid is now paying for its drugs via Part D lower than they were paying under the best price regime? Well take a wild guess.

Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor.

McLellan is also quoting the line that Part D is getting better prices, but the article has a raft of evidence suggesting that the drug companies think they're doing better, and the states are being asked to return more under the "clawbacks"--the amount they are being billed as they no longer have to provide drugs for the dual eligibles--than if they'd maintained their own programs. Several states are suing the Feds about that.

Meanwhile, I still think that they ought to be able to go to the drug companies and get "best price" for the rest of their Medicaid drugs (unless someone can tell me they have an exemption under the law). Which I guess in the end may make this a wash, if the drug companies have to provide even cheaper Medicaid drugs.

But for now it's just more evidence that Part D is a windfall for drug companies and health plans, and that AHIP's President has been caught being extremely economical with the truth. Not exactly news, I know.

POLICY: The health care, gay marriage re-run

Over at Spot-on I’m finally back to health care after a while off talking about footy. And I notice that San Francisco and Massachusetts share a couple of policy issues in common. It’s The health care, gay marriage re-run. As ever please read there and feel free to comment here.

Hospitals: Doctor in Katrina case arrested

From THCB’s NEW YORK DESK – Authorities in Louisiana have arrested a doctor and two nurses in connection with the deaths of scores of elderly patients at  Memorial Medical Center in New Orleans during the aftermath of Hurricane Katrina. Attorney General Charles Foti’s office said late yesterday that Dr. Ana Pou and nurses Cheri Landry and Laura Bubo have been charged with murder in the deaths.  A spokeswoman for his office says: “We're not calling this euthanasia. We're not calling this mercy killings. This is second-degree murder."

Industry observers have wondered for months what  impact criminal charges would have on Tenet, which owns Memorial and three other hospitals in New Orleans. We now get to find out.  On Tuesday, the company announced that it is selling Memorial and two other hospitals to the local Ochsner Health System. It is not clear how the charges will affect the deal.

TECH/POLICY/RANDOM: Monday update

Apologies for the quiet start today. A few things to keep you going with while I work on some other stuff off-line

MyMedwork is a MySpace/Linked in for physicians which has funding from a business accelerator started by bunch of big name mid-west medical orgs (including the Cleveland Clinic). Hey I (re-)met my fiancee on Linked-In so there must be something to this social networking stuff?

The first rumblings in the real business of health care—how much Medicare pays for what—are starting up. CMS is rattling the saber, and somehow managing to divert the attention onto 3M which is attempting to redesign DRGs and getting it in the neck for its troubles, apparently. Of course this is the beginning, not the end of a very long and ongoing process. The same thing is going on on the physician side around changes in the RVS system. The health plans have been muddying this water for some time, as I noted in my article about the punking of Milt Freudenheim back in June.

I’ve been having some fun backchat with Michael Cannon at Cato (the thinking man’s libertarian think-tank) over his riposte to my piece about Medicare HSAs. Well worth reading his response. More on that when I get my act together to edit our emails…Meanwhile over at Cato’s blog you should read anything Radley Balko’s written. He’s doing the best job in America about tracking the western liberal Democracies’ almost imperceptibly slow movement towards becoming authoritarian states. Did you know that “swearing” in public in the UK can now warrant a $130 on the spot fine at the sole discretion of the police?

Finally, working on some stuff on the new San Francisco health plan, which will emerge at Spot-on soon—now that I’m banned from writing about soccer for quite some time!

 

 

BLOGS: Start the weekend early

Busy today—see ya Monday

TECH: Comparing chronic disease management systems with EMRs

My favorite EMR consultant, Laura Jantos (from ECG in Seattle)—who retains that title despite owing me lunch since 1995—has a report out from the California Health Care Foundation about tools for managing disease management systems. The very short  summary is that souped up DM registries are pretty good value for money compared to EMRs. This is deep in the weeds stuff, but if you care about chronic care programs, you should read it.

TECH: Uh-oh, dissent in the orthodoxy that EMR will save money

In his Health Affairs piece It Ain't Necessarily So (which steals its title from my one Health Affairs article on which I was 4th banana author back in 1994) Jaan Sidorov claims that merely introducing “The Electronic Health Record” is unlikely to reduce overall system health care costs.

Stone him I say! Stone him!

Oh, hang on, I mostly agree. Although I do think that EMRs, eventually, will improve patient care quality, which he kinda doubts. But to actually reduce health care costs? Nice try RAND, CITL et al, but to do that requires limiting the amount of money put into the system. And that leads to unpleasant consequences for the main actors in the system. And as the Industry Veteran often reminds us, the whole IT thing is a side show helping us avoid that (eventual) conversation.

HOSPITALS: Apparently they're shooting them down in Texas.

Additional light shed on Houston Healthcare firings.

I can’t claim to know anything about this, other than isn’t it a little rare for this type of mass firing in the rather clubby hospital industry? Usually grand larceny and Medicare fraud is required, and sexual harassment is insufficient! And even then it takes all kinds of tooing and froing.

If you know more please comment. 

DISEASE MANAGEMENT BOSTON JULY 30 - AUG 2
At a three day conference in Boston MA, scheduled between July 31 and Aug 2, industry leaders from managed care companies, employer groups purchasing healthcare services, providers, third party administrators, physicians, healthcare technology players, nursing and pharmacy practitioners, disease management experts will meet at the 4th Annual Disease Management Conference. The event is posted online at www.srinstitute.com/ch142

BLOGS: Nurses--lots of them

Did you know that there were 4 million nurses in America? OK I made that up, but there are about 3 million RNs, not that all of them are working as nurses. I tell you this because virtually all of them have their own blog and most of those are in the nurses carnival called Change of Shift. This may be why there’s such a nursing shortage, as they’re all writing blogs instead!

TECH: Instapundit on Kessler

Andy Kessler was on THCB plugging his book in a fun way the other day. Now he’s getting closer to the blogging big time with InstaPundit Glenn Reynolds reviewing his book over on Oil Company Central. And (gasp) I agree with Reynolds’ take.

BLOGS: HWR is up

Oops—I forgot to submit this week, but Health Wonk Review #11 is up at the Healthcare Economist.

QUALITY: Yogurt--health food or dessert?

At The Doctor Weighs In spoilsport Pat Salber tells you that yogurt is not a health food! As I like (sweetened) yogurt — as oppsed to the natural rubbish — that’s obvious to me. The Matthew Holt test is, if I like it, it’s bad for you.

POLICY/POLITICS/HEALTH PLANS: HSAs for Medicare? Crazy but apparently true

So the HSA ideology has wormed its way into CMS, and now Medicare is seeking proposals for its Consumer-Directed Health Plan demonstration. Those taxpayers who can do basic math might wonder why you’d want to to give healthy Medicare beneficiaries cash for health services that they’re not going to use, while taking that cash away from the pot that pays for the sick beneficiaries that do use said services. But we’ve asked that question so many times before and no-one on the free market side dare answer it. And I guess you might say, why not give the taxpayers money straight to the “healthys” instead of laundering it through Medicare Advantage plans as we’re doing it now so that they can hand out free gym memberships to seniors and boost their executives’ stock holdings.

But given that risk adjustment is coming to Medicare Advantage, it may be that that gravy train is ending. Perhaps we’ll get to see if the private plans really can stand on their care management merits—and there’s so much fat in Medicare that they ought to be able to, easily.  Although they failed to do so in the late 1990s.

However, it’s just bizarre to increase the costs of a tax payer funded universal risk pool by allowing people who are not paying into it to withdraw cash from it. So the only real explanation is that CMS and its political masters in the White House are eventually intending to put the entire system into a high-deductible plan and not fund the amount below the deductible.  Just the same as most employers are doing (as I explained in this Spot-on piece about Intel).  That of course makes perfect sense for the government and the taxpayer. Until, that is, the seniors find out! I wouldn’t want to be in charge of Medicare when that happens, remember what those seniors did to Rostenkowski!

QUALITY/PHYSICIANS: Klein on malpractice

Ezra Klein has written a pretty good state of play about Medical Malpractice over at Slate. As you know I’m all for putting the solution for malpractice within the context of an overall medical error/practice guideline/EBM policy. Of course, politically the AMA and the docs are being used by the “tort reform” lobby who don’t give a rat’s arse about doctors or patients but are using them as sympathetic front men in their campaign to make corporate malfeasance unpunishable by any branch of government. So politically I wish the Democrats would sell out the trial lawyers on this one and work towards a wider solution (as Ezra suggests they might do). Not very likely of course, but slightly more plausible than the AMA cutting a deal, or the Republicans doing the right thing.

OFF-TOPIC: For those of you missing the world cup

Here it is — the Zidane Head Butt Game

QUALITY/PHARMA: Someone's going to get fired at the DEA for sure

The WSJ writes about a serious scientific study of the hallucinogen in magic mushrooms.  As you might expect virtually all of the participants thought that the sessions had a very powerful effect and 60% of the clinical trial participants said that effect was very positive indeed. But 30% of the cases felt incredibly bad effects, largely increasing paranoia. That’s not much of a surprise—people react differently to different drugs. The researchers are interested in seeing if these drugs (and presumably others like MDMA/Ecstasy) have value in treating psychiatric cases.

What’s amazing is that someone in the DEA signed off and allowed this research. After all, this is a substances banned for hysterical political reasons and, like LSD its synthetic equivalent, no one is pretending that they’re not very powerful. Of course the government does allow equally powerful psychotropic drugs to be widely used and dispensed with a false pretense that somehow their use is morally different.

The main differentiator is of course what the government will allow to go through clinical trials. Now that an approved trial of one class of banned drugs that may have a positive effect has been allowed, how can the DEA justify the continued delays in granting permissions for real trials of another banned drug that we all know has significant medicinal qualities? They can’t justify it morally or rationally or even legally, but they certainly continue to raid medical marijuana dispensaries to justify their existence, their power and their budgets. So when word gets out that someone inside the DEA made a rational decision on allowing a study that counters the drug warriors’ propaganda—well, I’m sure their career is on the outs.

POLICY/QUALITY: Reclaiming the right to die; book review by Mitchell Berger

Mitchell Berger volunteered to write a review of  William Colby’s, Unplugged: Reclaiming Our Right To Die in America (2006, American Management Association, 272 pp., $24.95 hardcover), and an excellent review it is too:

High-profile legal cases such as those involving Karen Ann Quinlan, Nancy Cruzan and Terri Schiavo and their families coupled with improvements in medical technology have forced growing numbers of patients and their family members, health care providers, judges, lawyers and legislators to confront difficult end-of-life dilemmas. Because of his own background as an attorney for the Cruzan family for four years, supporter of the hospice movement and contributor to the 1990 Patient Self-Determination Act, which requires hospitals to inform patients in writing about health care advance directives such as living wills, attorney William Colby, author of Unplugged: Reclaiming Our Right to Die in America, brings unique insights to his discussion of these cases, evolving medical technology and the overarching issue of end-of-life care in America.

Colby’s book includes an extensive discussion of the Quinlan, Cruzan and Schiavo cases. He describes how relatively recent advances in scientific knowledge, such as an improved understanding of brain function, brain death and vegetative states and advances such as cardiac defibrillators, artificial respirators, feeding tubes, percutaneous endocscopic gastronomy (PEG) tubes (a method of providing nourishment to patients using a tube inserted through an endoscopic procedure which is simpler than standard feeding tube insertion), have led to new challenges as society struggles to reconcile the benefits of these technologies with respect for the individual’s quality of life and right to live and die in a manner reflecting their beliefs. Colby devotes an entire chapter of his book to explaining the ethical and medical issues associated with feeding tubes and PEG; he explains how PEG tubes, originally intended for pediatric patients, are now used routinely in cognitively impaired elderly persons who can no longer eat on their own.

While many people would want every reasonable measure taken to prolong and maintain their life regardless of their condition, many others would not want to live in a state where they are no longer able to respond to their loved ones and the world around them. When Nancy Cruzan, then a 25-year old Missouri woman, was left in a persistent vegetative state following a car wreck in 1983, her father authorized insertion of a feeding tube. Colby explains that in a persistent vegetative state a patient may be awake and even smile or move their eyes, however these movements are completely involuntary and in fact the patient has “no thinking, no feeling, no consciousness” (p. 10). When it became clear as first months and then years went by that Nancy Cruzan would never recover from her condition, Cruzan’s family tried to act on their shared “belief that  [she] would want the feeding tube removed” (p. 89). After many years of legal proceedings both in Missouri and at the federal level, including a U.S. Supreme Court decision in 1990, the family eventually was granted the right to remove the feeding tube based on evidence of what Nancy Cruzan herself would have wanted. Extensive publicity surrounded this case – indeed the Cruzan family allowed PBS’ Frontline to document their experiences -- and Colby describes how the Cruzan family’s experience altered public opinion about end-of-life care both in Missouri and elsewhere and encouraged Missouri Senator John Danforth and others to sponsor the Patient Self-Determination Act.

In perhaps the most interesting portion of his book (Chapters 1-3), Colby provides an informative and balanced discussion of the most recent and perhaps controversial end-of-life care case involving Terri Schiavo. Unlike Nancy Cruzan’s family, Schiavo’s relatives were bitterly divided about what she would have wanted and what was best for her. Colby discusses his own approach to death and dying issues and even includes his own health care power of attorney as an example for others (Chapter 10; Appendix). However, he also notes the limitations of laws and legal documents. For instance, Colby describes the “institutional glide path” which dictates that many hospital patients will receive “aggressive,” often unwanted end-of-life medical care; the “glide path” reflects the tendency of health care providers and institutions to treat patients in customary, technology-intensive ways due to such factors as medical education, institutional culture and fear of litigation.

To help ensure that the end-of-life care we receive reflects our values and desires, Colby emphasizes the importance of talking at length with family members, friends and health care providers about how we would want to be cared for if our capacity to make our own decisions should ever be impaired by illness or injury. This dialogue will help ensure that our family members and health providers are not forced to confront complex dilemmas in tense and emotional circumstances with their loved one’s wishes unclear.

Colby is a strong supporter of hospice as one option for end-of-life care. Indeed, he serves as a Senior Fellow of the National Hospice and Palliative Care Organization in Washington, D.C., and the foreword to his book is contributed by that organization’s chief executive officer. He explains the rise of hospice care, which he characterizes as a “hidden jewel,” and notes that growing numbers of patients are opting for hospice (750000 of 2.5 million Americans who died in 2005). Hospice emphasizes communication between patients, families and health care providers, symptom relief and palliative care (Chapter 15).

Though he clearly has strong opinions, Colby’s book is fair and even-handed in his treatment of the major legal and ethical issues and he includes chapters devoted to concerns about expanded recognition of the “right to die” expressed by religious organizations and persons with disabilities. The book is well-researched and well-documented, with numerous end notes, citations to outside sources, suggestions for further reading and contact information for such relevant organizations as the National Family Caregivers Association and National Institute on Aging. Overall, Colby’s book provides readers with excellent background about the key legal and scientific issues, good ideas for how to approach end-of-life care and strong motivation for initiating these sometimes awkward but critically important conversations with family members and health care providers.

POLICY: An Outcomes Primer by Eric Novack

THCB welcomes back regular contributor Dr. Eric Novack, who has something to say about outcomes as well as some recent snide comments made about orthopedic surgeons by a certain other poster on the site. In addition to blogging for THCB in his (oh so rare) free time, Eric is also the host of The Eric Novack show, which airs every Sunday on KKNT 960 AM in Phoenix. You can find an archive of his recent shows here.   

An Outcomes Primer

By ERIC NOVACK M.D.

Many in medicine view those of us in orthopedics as the ‘dumb bone doctors’ (or, according to the IV, much worse than that). Much of this stems from the basic idea that fracture care, or broken bone treatment, seems very straight-forward. Oh, but wait…

So here is a brief sense of how difficult it can be to evaluate outcomes even in the ‘simple’ area of a broken wrist. And, how it can be absurd to make the surgeon completely responsible?

The first question we need to ask is, “what outcome are we measuring”? Are we going to look at (a) has the bone healed? (b) how ‘good’ does the xray look- i.e. how close to ‘perfect’ are the bones lined up? (c) how is the patient’s function, and at what point after injury do you measure- months, years?

THCB is big on functional outcomes, so let’s just say that we care about wrist function 1 year after injury. But what kind of function? Range of motion? Return to work? Return to sports?

I’ll make it easy and say we’ll leave that to the patient and simply ask about satisfaction with ability to return to pre-injury functioning.

Stick with me- I know we are looking at the easy area of a broken bone. So, we are trying to determine functional outcomes 1 year after a wrist fracture.

Here is one way to look at the factors impacting the outcome:

1. Patient factors – age, motivation to get better, willingness to listen to medical advice and follow recommendations, nutritional status, other medical conditions, previous injuries, secondary gain issues (workers’ comp, lawsuits), body’s response to injury (i.e. inflammatory response to trauma)

2. Injury factors—severity of injury force (e.g. trip over dog vs. 60mph motorcycle crash), location of fracture (e.g. involving joint cartilage), degree of displacement (i.e. how ‘bad’ the xray looks), associated soft tissue injuries, associated injuries impacting treatment and rehab decisions

3. Surgeon factors—appropriate decision making, surgical technical skill, doctor-patient communication (discussing injury, options, risks, and expectations)

Rhetorically (and not), I ask- how much of the outcome can the surgeon possibly control?