What can we do about overuse of emergency rooms?

Come and get it!

Come and get it!

I’d expect an emergency physician with 35 years of experience to have some solid insights on why people come to the emergency room. Sure enough, Dr. Paul Auerbach delivers the goods in his Wall Street Journal opinion piece (Why ER Visits for Non-Emergencies Aren’t Going Away). In particular:

  • Patients can’t easily distinguish between true emergencies and non-emergencies
  • You can’t teach economics lessons to people when they are sick
  • Patients have learned they can get care in an emergency department more conveniently and quicker than in a community setting
  • Ambulatory physicians are culpable, because they encourage patients to go to the ER and don’t offer convenient hours
  • Emergency room use will continue to be heavy until key deficiencies in care delivery are addressed

So it was interesting that the Journal published five letters from people with different ideas. I disagree with four (all by doctors), and note that the fifth idea (by someone who may be a dentist) is already being implemented.

  • Dr. Ainslie thinks that “if ERs were forced to post prices, patients could decide what services they wanted to use.” That might work for an elective knee replacement, but doesn’t square at all with my experience in the ER. Am I really going to pick out what emergency services I want and exclude others? Who is going to have the time to discuss the costs and tradeoffs? Am I going to try my luck at a different ER if I don’t like the pricing at the first? Ridiculous
  • Dr. Dunn complains that primary care physicians like him spend half their time filling out documentation that offers no value add for the patient. He thinks docs should be paid “for the service they provide (without having to battle for reimbursement) and eliminate the non-value-added documentation.” This would boost the capacity of primary care physicians and reduce the need for emergency room use. I’m sympathetic to the paperwork complaint but I don’t think we can replace it with no questions asked fee for service. If Dr. Dunn is ready to take on global capitation for his population of patients then his idea might work. Even then there will be some paperwork
  • Dr. Geehr blames ObamCare. “ObamaCare, like its predecessor RomneyCare, promised fewer ER visits and more primary-care access. Government always fails to account for the unintended consequences of vast, new entitlement programs.” Actually, some proponents of ObamaCare (including me) did foresee the rise in ED utilization. Opponents didn’t think of this argument ahead of time, since they were so busy blaming the uninsured for clogging up the emergency department.
  • Dr. Brotherton writes, “the best way to reduce ER visits is for insurers to pay adequately for primary care.” Somehow –he doesn’t explain how– this will cause patients to go to their primary care doctors instead of the emergency room. I’ll give him the benefit of the doubt and suggest that he means higher payments will induce more physicians to practice primary care, but that would take quite a while to play out and still doesn’t address patient behavior.
  • David Lieberman wants hospitals to put urgent care clinics alongside emergency departments to keep the non-emergencies out. Not a bad idea and some hospitals are actually doing this. It works best when hospitals have a financial incentive to hold down costs

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

We want death panels!

Can you hook me up?

Can you hook me up?

From Kaiser Health News:

The public overwhelmingly supports Medicare’s plan to pay for end-of-life discussions between doctors and patients, despite GOP objections that such chats would lead to rationed care for the elderly and ill, a poll released Wednesday finds.

Of course it makes sense to pay physicians to discuss these difficult issues. The fear-mongering prompted by Sarah Palin’s characterizing these discussions as “death panels” has been harmful to patients and families.

It’s heartening to learn that most people have been able to cut through the nonsense on this one.

Image courtesy of foto76 at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Why drug price regulation should not be ruled out


I’m a proponent of free markets and in general defend drug companies in their price setting, especially when they’re introducing new, innovative products with real clinical and financial benefits. See, for example, Hooray for high-priced hepatitis treatment Sovaldi.

But we have to remember that the reason high prices can persist in the market is that drugs are protected by patents and other restraints on competition such as the orphan drug law. Those rights are monopolies granted explicitly by the government. There’s really nothing free-market about them. Since the government grants these rights it should also be able to regulate the benefits that result from them.

In many cases the government wisely stands back and lets the market do its work. The generic market for small molecule pharmaceuticals is a case in point. When it works well –which is most of the time– prices fall by 90 percent or more once a patent expires.

But there are exceptions, where the government should consider stepping in. One example (highlighted on this blog in 2007: Abusing the orphan drug law to rip off customers) is when an old, generic drug gains new intellectual property protections for a use that is already common.

Another example that’s becoming more common is when large molecule drugs go off patent. The government is making a big mistake with its ‘biosimilar’ approach, which wrongly tries to apply the generic drug precedent to products that can’t be copied exactly. Instead, as I’ve been advocating since 2006 (A better idea than biogenerics) would be better to leave the original manufacturer with a monopoly, post-patent expiration but to regulate the price. This would be fairer and safer for patients.

We’re hearing a lot of noise about drug prices from politicians, doctors, drug companies, and patients. I won’t repeat what they say here, since you can easily find it elsewhere. This is a substantive issue, with no black and white answers. I’m glad to see it being brought forward into the public sphere.

By healthcare business consultant David E. Williams, president of Health Business Group.

Mercy Virtual’s Randy Moore: ROI isn’t good enough (Podcast)

Randall Moore, MD. President of Mercy Virtual

Randall Moore, MD. President of Mercy Virtual

Mercy Health has been doing big things in digital health. Last year I interviewed EVP Shannon Sock after he spoke in Boston. And recently I met Mercy Virtual’s president, Randall Moore, MD at Qualcomm Life’s Connect2015 conference to ask him some follow-up questions after his talk.

  1. (0:10) You came out on stage and said ROI isn’t a high enough bar to cross. You really have to consider cash flow. Say more about that.
  2. (1:16) You showed a compelling video of a patient’s experience. How much of that is vision and how much is real? For example, do you really have ‘warm handoffs’ to the ER when someone arrives after calling ahead?
  3. (3:34) Many people at the conference have been sanguine about the new ‘value based’ models. But you said hospital-based ACOs are likely to fail. Why?
  4. (6:07) You discussed radically reducing length of stay and increasing market share to stay viable. Does your business model rely on putting your competitors out of business?

By healthcare business consultant David E. Williams, president of Health Business Group.

Health Wonk Review is up at Colorado Health Insurance Insider

Check out the Fall Colors edition of the Health Wonk Review at Colorado Health Insurance Insider.

You will learn the best and worst days to be admitted to the hospital. Plus view posts on physician ethics, ACA replacements, 2016 premiums, work comp spending, census data, IT, and medical records.

Emotion tracking tools –only for trivial purposes?

Who am i?

Who am i?

I was surprised that the Boston Globe’s (Waltham firm helps computers learn empathy by mapping the human face) highlighted such unimportant opportunities for the technology. Here’s what MIT Media Lab spinoff Affectiva is doing, according to the Globe:

  • Helping companies measure emotional responses to advertising
  • Spitting out pieces of chocolate for Hershey’s when someone smiles at the machine

Maybe that’s not so bad for initial applications, but what’s down the road sounds pretty unimportant as well

“If a student got stuck on a tough math problem, an empathetic school computer would recognize the confused look on his face, and instantly offer additional help. An office laptop might see that a worker is bored, and suggest that he take a coffee break or play a simple computer game. A TV that notices that nobody laughed at last night’s Adam Sandler movie might suggest Woody Allen next time.”

Give me a break. A much more profound application for these tools will be to give people better insights into others’ emotions in live one-on-one and group interactions. It will be especially helpful for people with autism and Asperger’s, but it will also be useful for the average person to better understand how others react to them. The technology could (and I assume will) be built in to a next generation of Google Glass or similar.

I know some people who could use such a tool.

I’m not suggesting anything that hasn’t already been thought of, but the Globe should have done a better job reporting on this.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.